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CHS20/294

Canberra Health ServicesProcedure Bowel Assessment and Management (Adults and Children)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Bowel Assessment and Management.....................................................................2

Section 2 – Constipation...........................................................................................................3

Section 3 – Administration of rectal suppository......................................................................5

Section 4 – Administration of enema - Adults...........................................................................5

Section 5 – Bowel washout – Adults.........................................................................................6

Section 6 – Flatus tube insertion – Adults.................................................................................8

Section 7 – Manual evacuation of faeces..................................................................................9

Section 8 – Bowel management for patients in the community.............................................11

Section 9 – Bowel protocol for enteral and oral fed patients in Intensive Care Unit (ICU).....12

Section 10 – Instaflo® Bowel Management System – Intensive Care Unit..............................13

Evaluation............................................................................................................................... 17

Related Policies, Procedures, Guidelines and Legislation.......................................................17

References.............................................................................................................................. 18

Definition of Terms................................................................................................................. 19

Search Terms.......................................................................................................................... 19

Attachments............................................................................................................................20

Attachment 1: Bristol Stool Chart.......................................................................................21

Attachment 2: Instaflo® troubleshooting guide..................................................................22

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Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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Purpose

The purpose of this procedure is to provide clinicians with information on the safe and effective bowel management of patients in the hospital and in the community setting.

Back to Table of Contents

Scope

This document applies to adults and children under the care of Canberra Health Services (CHS), both in hospital and in the community setting.

This document applies to the following CHS staff working within their scope of practice: Medical Officers Nurses and Midwives Allied Health Clinicians Students under direct supervision Assistants in Nursing.

Assessment and management of faecal incontinence is not covered in the scope of this document – for faecal incontinence see CHS Continence Assessment and Management Procedure.


Section 1 – Bowel Assessment and Management

Bowel assessment in the acute or the community setting may include: patient history and contributing factors to bowel dysfunction physical examinations - abdominal and rectal bowel record chart (for 14-28 days).

Bowel assessment tools can be found on the Clinical Record Forms Register including: Paediatric Bowel Assessment Continence Assessment Bowel Diary

Bowel management is multidimensional and requires a multidisciplinary approach.

Consider referral to: dietitians for patients who have poor nutritional status, sudden changes in bowel

function or chronic constipation physiotherapists for patients with changes in activity or mobility levels



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occupational therapists for patients with altered activity levels, requiring equipment to access the bathroom safely or maintain safety in the home. This can include pressure relieving devices

Community Care Continence Service for patients (adults and children) with constipation, faecal incontinence and other bowel issues. Refer through Central Health Intake (CHI) phone (02) 5124 9977 or fax (02) 5124 1082.

My Aged Care (MAC) for patients 65 years and over, or Aboriginal and Torres Strait Islander 50 years and over via www.myagedcare.gov.au or 1800200422. To refer to MAC patients must be more than six weeks post discharge from hospital.


Section 2 – Constipation

Constipation refers to difficulty or straining with bowel movements, and infrequent bowel movements over an extended period of time. Symptoms associated with constipation include hard/dry stool, bloating and abdominal pain accompanied with a sense of incomplete evacuation.

Conservative management of constipation:

Diet, fluid and exercise Adults (19 years and over):

o Diet should contain 25-30 grams (g) of fibre from a variety of sources. A gradual increase in fibre is recommended. As fibre is increased, fluid intake must also be increased to 2 litres (L) per day.

o Total fluid intake should be between 2.1L (female) to 2.6L (male) per day, unless otherwise specified by the patient’s medical officer. Encourage patients to take regular amounts of fluid throughout the day. Extra fluid is recommended in summer.

o Dietitians can provide individualised advice on the role of a low FODMAP diet and probiotics for the management of constipation.

Children (4 years - 18years):o Adequate intake of dietary fibre for infants, children and adolescents can be found

on the National Health and Medical Research Council website http://www.nrv.gov.au/nutrients

o Recommended daily fluid requirements (water, milk and other drinks) is approximately 50-60 millilitres per kilogram per day (mL/kg/day) plus fluids from other sources. Guidelines available on the National Health and Medical Research Council Website https://www.nrv.gov.au/nutrients/water

o Also see Royal Children’s Hospital Melbourne clinical practice guideline for Constipation website: https://www.rch.org.au/clinicalguide/guideline_index/Constipation/

Encourage regular exercise. Patients with a mobility impairment may benefit from exercises such as pelvic tilt, low trunk rotation and single leg lifts.



https://www.rch.org.au/clinicalguide/guideline_index/Constipation/

https://www.nrv.gov.au/nutrients/water

http://www.nrv.gov.au/nutrients

http://www.myagedcare.gov.au/

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Note: For patients at end-of-life, increasing dietary fibre for the treatment of constipation can compound the problem. Use of softeners and/or stimulants should be considered.

Note: For patients with spinal cord injury, the amount of fluid needed to promote optimal stool consistency must be balanced with the amount needed for bladder management. Adult patients with urinary catheters may drink a maximum of 2-3L maximum per day. Adult patients who do intermittent self-catheterisation may require less fluid to fit with their individual program, normally around 2-2.5L per day.

Toileting Strategies Encourage a prompt response to pass faeces, going to the toilet at a regular time each

day, eating or drinking approximately 30 minutes prior to toileting to stimulate the gastrocolic reflex.

An upright position is recommended during defaecation. Encourage patients to sit with both feet supported on a footstool so knees are slightly higher than hips, lean forward with straight back and rest elbows on knees. Without straining, relax and widen the back passage, advise patients not to hold their breath and relax the abdominal wall. When finished, advise the patients to contract their pelvic floor muscles.

Where a patient is unable to sit, a left side-lying position while bending the knees and moving the legs toward towards the abdomen is recommended.

Patients with mobility impairments (and those at risk of pressure injuries) would be recommended to have a padded toilet seat or commode, with a backrest, footrest and side rails.

Pharmacological interventions Laxatives/aperients are useful for short-term treatment of acute constipation, and may

only be recommended for long-term management of constipation by medical staff. If organic disease is not the cause of constipation, pharmacological treatment is

appropriate on a short-term basis. It should be considered only after non-pharmacological interventions have been unsuccessful.

Surgery Usually reserved for severe intractable disease resulting from a slow colonic transit. The most common procedure is a subtotal colectomy and ileo-rectal anastomosis or

colectomy resulting in the formation of a permanent stoma. Refer to the CHS Stoma Management – Adults, Adolescents, Children, Infants and Neonates Procedure.

Patient /carer education Educate patients/carers about the wide range of normal bowel routines and symptoms related to abnormal bowel evacuation. The patient should be encouraged to report significant or prolonged change in their bowel habit to their General Practitioner (GP).




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Section 3 – Administration of rectal suppository

Suppositories assist in the evacuation of faeces from the rectum, or are used to administer medication for absorption through the rectal wall. A suppository is inserted into the rectum and dissolves at body temperature.

Equipment suppository water-soluble lubricant (e.g. KY gel, or water for glycerine suppository. If the patient is

at risk of Autonomic Dysreflexia use lignocaine 2% gel five minutes prior to procedure. See CHS Autonomic Dysreflexia Procedure.)

bedpan, commode or toilet disposable protective pad - blue sheet personal protective equipment (PPE) including disposable gloves, gown and safety

eyewear.

Procedure (Adults)1. Check the authorised prescriber order (Medical Officer or Nurse Practitioner).2. Inform the patient of the procedure, obtain informed consent and ensure privacy.3. Ensure patient has emptied bladder to prevent discomfort.4. Perform hand hygiene by either hand washing or using alcohol based hand rub (ABHR).

Don PPE and assemble equipment. 5. Assist the patient to adopt the left lateral position (to facilitate contact with rectal

mucosa for effective bowel action) with knees flexed and blue sheet in place.6. Perform hand hygiene, don clean gloves and use generous amount of lubricant. 7. Perform Digital Rectal Examination (DRE).8. Remove wrapping, lubricate suppository and insert beyond the anal sphincter and

against the rectal mucosa. 9. Encourage patient to retain suppository for 15-20 minutes, lying in the left lateral

position. 10. Assist patient onto bedpan, commode or toilet if necessary.11. Observe the amount and form of the bowel motions, using the Bristol Stool Chart as a

guide (see Attachment 1).12. Undertake DRE to assess outcome if in doubt. 13. Discard waste appropriately. 14. Remove gloves and other PPE, and perform hand hygiene.15. Document in clinical record.




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Section 4 – Administration of enema - Adults

An enema is introduced into the rectum or lower colon with the purpose of producing a bowel action or instilling a medication.

There are two main types of enemas: Evacuant: Used to evacuate the bowel, they may be small or large volume and are

usually commercially prepared. Retention: A solution used primarily for local effects, to be retained for a specific period.

Equipment enema at room temperature water-soluble lubricant (e.g. KY gel, or if at risk of Autonomic Dysreflexia use lignocaine

2% gel five minutes prior to procedure) Bedpan, commode or toilet Disposable protective pad - blue sheet PPE

Procedure 1. Check the authorised prescriber order (Medical Officer or Nurse Practitioner).2. Inform patient of the procedure, obtain informed consent, and ensure privacy. 3. Ensure patient has emptied bladder, to prevent discomfort.4. Perform hand hygiene, don PPE, and assemble equipment.5. Assist the patient to adopt the left lateral position (to facilitate contact with rectal

mucosa for an effective bowel action) with flexed knees and blue sheet in place. 6. Drape the patient with a sheet or blanket, and withdraw sheet to expose the anal area.7. Perform hand hygiene, don clean gloves use a generous amount of lubricant. 8. Perform DRE if necessary.9. Remove cap from enema and lubricate nozzle.10. Encourage patient to relax and take deep breaths. 11. Part the buttocks. Gently insert the enema tip 5cm into rectum (on an exhalation) and

slowly squeeze the content into rectum.12. Maintain pressure on the enema tube to prevent flow back of liquid returning to the

tube while removing nozzle from rectum.13. Encourage patient to retain enema for 15-20 minutes, lying in the left lateral position.14. Assist the patient onto a bedpan, commode or toilet if necessary. 15. Observe the amount and form of the bowel motions, use Bristol Stool Chart as a guide

(see Attachment 1)16. Undertake DRE to assess the outcome of the enema if in doubt.17. Discard waste appropriately. 18. Remove gloves and other PPE and perform hand hygiene. 19. Document in the clinical record.




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Section 5 – Bowel washout – Adults

Bowel washouts are performed with the purpose of: stimulating peristalsis and removal of faeces or flatus cleansing the colon and rectum in preparation for an examination or a surgical

procedure removing toxins from the large intestine softening faeces and lubricating the rectum and colon.

Equipment bowel washout solution as ordered irrigation set (can, rubber tubing, and clamp) or Coloplast irrigation set medium tube adaptor disposable rectal catheter or short length female Foley’s catheter lubricant PPE absorbent under pad clinical waste receptacle general waste receptacle bedpan or commode intravenous (IV) pole/stand

Procedure 1. Check authorised prescriber order (Medical Officer or Nurse Practitioner).2. Explain the procedure, obtain consent and ensure privacy.3. Perform hand hygiene by either hand washing or using ABHR, don PPE and assemble

equipment.4. Assist the patient to assume the left lateral position and cover the patient with a sheet.5. Ensure the solution is at body temperature.6. Perform hand hygiene by either hand washing or using ABHR, and don PPE.7. Connect the can, rubber tubing and rectal catheter or Coloplast irrigation set.8. Suspend the can from the IV pole for priming.9. Perform hand hygiene by either washing hands or using ABHR. 10. Don clean gloves.11. Inspect the anus for the presence of haemorrhoids, bleeding or irritation. Review the

procedure with the treating Medical Officer, or GP for community patients, if any of these are present.

12. Pour approximately 240mL of solution into the can.13. Expel air from the tubing, then clamp.14. Liberally apply lubricant to the catheter.15. Ask the patient to breathe deeply. 16. Part the buttocks and gently introduce the rectal catheter approximately 7-10cm into

the rectum.17. Allow the solution to flow into the rectum, holding the can 30-45cm above the level of

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Note: If the patient complains of pain, exhaustion or great discomfort during the procedure, cease the flow of solution for a few minutes then slowly recommence. Hold the irrigation can no higher than 44cm above the level of the patient’s buttocks.

18. Clamp the tube when the solution has been instilled into the rectum.19. Disconnect the can and hold the tube over the bedpan. Unclamp the tube.20. Clamp the tubing when the solution flow ceases.21. Reattach the can and repeat the procedure with a further 240mL of solution.22. Continue the procedure until the return is clear.23. Remove the catheter when the last of the solution has flowed from the rectum.24. Clean the anal area.25. The patient may sit on a bed pan.26. Disassemble the equipment, discard disposable equipment and gloves. 27. Perform hand hygiene. 28. Remove safety glasses or goggles and gown.29. Perform hand hygiene. 30. Observe amount and nature of return.31. Document on the patient’s medication chart.32. Document in clinical record:

o amount of solution instilledo patient’s reaction to the procedureo amount and nature of return.


Section 6 – Flatus tube insertion – Adults A flatus tube is inserted to relieve abdominal distension caused by flatus. The insertion of a flatus tube will be prescribed by a Medical Officer.

Assess the patient’s heart rate before, during and after the procedure, as rectal stimulation can cause bradycardia due to vagal nerve stimulation.

Equipment rectal tube lubricant disposable dish and water disposable protective pad - blue sheet draw sheet PPE tape measure



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Procedure 1. Check Medical Officer order. 2. Discuss the procedure with the patient, obtain informed consent and ensure privacy.3. Perform hand hygiene, don PPE, and assemble equipment.4. Measure abdominal girth.5. Assist the patient to assume the left lateral position, with under pad in place. Cover the

patient with a drawsheet.6. Attend hand hygiene.7. Assess the patient’s pulse before examination.8. Don gloves and protective glasses.9. Expose the anal area and inspect for haemorrhoids, bleeding or irritation. Contact

Doctor if concerned and document.10. Lubricate the tip of the rectal tube.11. Place the distal end of the tube underwater.12. Position the dish near the anal area.13. Encourage the patient to breathe deeply.14. Part the buttocks and gently insert the rectal tube approximately 5-8cm into the rectum,

leave the rectal catheter in place for the prescribed time.15. Observe for air bubbling and reduction in abdominal distension.

Note: Cease the procedure if the patient experiences pain. The rectal catheter can be left in place for a maximum of 20 minutes only.

16. Remove the rectal catheter once the air bubbles cease.17. Clean the anal area.18. Discard equipment, remove gloves, and attend hand hygiene.19. Measure abdominal girth.20. Assess the patient’s pulse after examination.21. Document in clinical record:

o results of flatus tube insertiono the patient’s level of comfort/discomfort post procedureo decrease in abdominal distension.


Section 7 – Manual evacuation of faeces

Manual evacuation may be used for patients with lower motor neurone bowel dysfunction (e.g. spinal cord injury (SCI) below T12) as destruction of the sacral reflex defecation centre results in loss of defecation reflex. In patients with lower motor neurone bowel dysfunction (areflexic bowel) the main goal is to encourage a firm, formed stool that can be retained between bowel care sessions and easily evacuated.



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In those patients with a spinal cord injury above T6 manual evacuation may need to be attended if the patient is experiencing an episode of Autonomic Dysreflexia and the identified cause is an overextended rectum/full lower bowel. Extreme caution and specific interventions are required as per the CHS Autonomic Dysreflexia Procedure.

Manual evacuation may need to be attended when impacted stool in the rectum is unable to be removed in any other way. This is sometimes required for patients with neurogenic bowel changes associated with diseases such as Multiple Sclerosis and Parkinson’s Disease.

In other patients without neurogenic bowel dysfunction, manual evacuation of faeces is seen as a last resort management where all other methods of bowel evacuation have failed.

Manual evacuation may be needed to remove stool prior to the insertion of a suppository or enema for the medication to be effective.

Equipment water-soluble lubricant (for patients with spinal cord injury at or above T6 use lignocaine

2% gel, five minutes prior to procedure) PPE including disposable gloves, gown and safety eyewear disposable protective pad - blue sheet bedpan or collection container.

Procedure In consultation with the Medical Officer, establish that there are no contraindications that may place patients ‘at risk’. Examples include, but are not limited to: cardiac conditions with arrhythmias (stimulation of the vagus nerve in the rectal wall

can slow the patient’s heart rate) bowel perforation, rectal bleeding or anal fissures distress, pain, discomfort, bleeding or anti-clotting medication recent rectal/anal surgery or trauma.

1. Discuss the procedure with the patient, obtain informed consent and ensure privacy.2. Ensure that patient has emptied bladder.3. Perform hand hygiene and don PPE.4. Assist the patient to adopt the left lateral position with knees flexed, and blue sheet in

place. Drape the patient with a sheet or blanket and withdraw sheet to expose the anal area.

5. Lubricate gloved index finger and anus generously with lubricating gel.6. Encourage patient to relax and breathe regularly.7. Part buttocks and insert the gloved finger into the rectum slowly and gently.8. If stool is solid mass, push finger into the centre, split it and remove small sections until

none remains. If small hard stool, remove a lump at a time.9. Patients may assist by performing Valsalva manoeuvre. Patients with areflexic bowel or

lower motor neurone bowel dysfunction may respond to the Valsalva manoeuvre during manual removal to assist with bowel emptying.



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10. Document the amount and the nature of the return in the clinical record.

Note: Valsalva manoeuvre should not be performed on a patient with a full bladder due to risk of vesico-ureteric reflux. It is also contraindicated for individuals with cardiac problems and hypertension. With prolonged straining, Valsalva can also predispose to haemorrhoids and rectal prolapse over time.


Section 8 – Bowel management for patients in the community

Routine bowel care is not provided by the CHS Community Care Program (CCP) Community Nursing Service. Non-Government Organisations provide routine bowel care as part of a personal care package.

An exception to this are the Assistants in Nursing (AINs) employed by CHS Community Nursing Service who provide personal care for a complex care patient in the community under specific agreement. AINs in the community attend to bowel care under the direction of a registered nurse.

CCP nurses offer assessment, advice and review of bowel regimes. CCP nurses will only administer short-term rectal medication if a medical order is in place and a Registered Nurse Level 2 will only perform DRE for the purpose of assessment.

The left lateral position is recommended for most bowel interventions. Where there is a clinical reason why the left lateral position can’t be adopted by the patient, an alternative safe ergonomic recommendation is to be implemented following manager approval. The recommended procedure is to be clearly documented in the care plan and progress notes.

CCP nurses should consult with the CCP Continence Clinical Nurse Consultant (CNC) as required.

When caring for patients with a spinal cord injury at or above T6 community nurses will ensure the patient and their carers are educated about the risk factors, signs and symptoms of Autonomic Dysreflexia. See CHS Autonomic Dysreflexia Procedure. The admitting nurse will ensure that an appropriate management plan is in place for bladder and bowel care, and that medical orders for catheter insertion and medication administration are documented in the patient’s file. The emergency management plan will be documented in the patient’s file and the patient and their carers will be made aware of the plan.

In those patients with a spinal cord injury above T6, manual evacuation may need to be attended to if the patient is experiencing an episode of autonomic dysreflexia and the cause of the dysreflexia is an over distended rectum/full lower bowel. Extreme caution and specific



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interventions are required to manage this. Each patient should have an individualised management plan and bowel regime.


Section 9 – Bowel protocol for enteral and oral fed patients in Intensive Care Unit (ICU)

This protocol does not apply to: patients with signs and symptoms of bowel obstruction (abdominal discomfort and

distention, nausea and vomiting) patients who have had recent gastro intestinal surgery Patients with Spinal injury patients excluded by the Intensive Care Unit (ICU) medical team.

Procedure Step 1. Once enteral or oral diet has been started consult doctor to prescribe:

o Macrogol 3350 (Movicol®) once daily (dissolved in 125 mL water) o Docusate/senna 50mg/8mg (Coloxyl® & Senna) two tablets twice dailyo 40mL warm water three times daily via enteral tube.

If bowels open within 3 days of commencing protocol continue step 1. If bowels not open within last 3 days on protocol progress to step 2.

Step 2. Rectum Full Continue step 1 and consult doctor to prescribe:

o one bisacodyl and two glycerin suppositories. If bowels open go back to step 1. If bowels not open within 24 hours go to step 3.

Rectum empty Continue step 1. Observe for signs & symptoms of bowel obstruction. Inform doctor regarding unopened bowels & empty rectum.

Step 3. Continue step 1 and consult doctor to prescribe phosphate enema (Fleet® Enema). If bowels open return to step 1. If bowels not open within 24 hours go to step 4.

Step 4. Consult doctor for repeat phosphate enema (Fleet® Enema) and increased aperients +/-

manual evacuation. If bowels opened return to step 1.



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If bowels not open continue step 4 every 24 hours until bowels have opened.

DiarrhoeaIf diarrhoea occurs (i.e. 3 large liquid stools within 24 hours) withhold oral aperients for 24 hours then recommence bowel protocol at step 1.If diarrhoea persists cease macrogol 3350 (Movicol®) and then reduce docusate/senna 50mg/8mg (Coloxyl® & Senna) to two tablets ONCE daily.

Record frequency & type of bowel motion in Metavision on the ICU flow chart and the fluid balance chart, using the Bristol Stool Chart (see Attachment 1).


Section 10 – Instaflo® Bowel Management System – Intensive Care Unit

The Instaflo® Bowel Management System is used in the ICU when patients are assessed as having Bristol Stool Chart type 7 (watery) stools.

The Instaflo® aims to: reduce excoriation from faecal incontinence prevent risk of infecting wounds (e.g. pressure ulcers, burns, grafts) reduce the risk of infection to other patients and health care professionals.

A Medical Officer must prescribe the use of the Instaflo®.

The Registered Nurse must perform an initial assessment to determine if the patient meets criteria for use of the Instaflo.

Indications patients requiring faecal diversion for the protection of wounds, burns, flaps or grafts patients with infectious stool (e.g. VRE, MRSA, C. difficile) minimising risk of excoriation from faecal incontinence in diarrhoea not controlled by

medical therapy.

Contraindications patients who have had previous colorectal surgery involving an anastomosis, or who

have had any rectal surgery or recent anal or sphincter reconstruction patients with impacted stool if the patient’s distal rectum cannot accommodate the inflated volume of the retention

cuff or if the distal rectum/anal canal has a stricture secondary to tumour, inflammatory condition, radiation injury or scarring

patients who have a known sensitivity or allergy to the materials used in the device.

Before using The Instaflo®



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The bowel management system should be ordered by a Medical Officer and documented in the patient’s medication chart and clinical record.

The bowel management system is available in two catheter sizes either 4cm or 6cm (6cm is the most frequently used adult size).

The colon and rectum should be clear of all stool/faecal matter prior to insertion of the bowel management system.

Note:A stool management protocol should be in place for patients who have had insertion of the bowel management system for skin/wound protection. This is to ensure that the stool remains soft enough to ensure flow and prevent blockage until such time that contamination is no longer a risk. The protocol will be ordered by the medical team and reviewed daily.

Tips for inserting the Instaflo® The catheter tip is folded and inserted into the rectum and attached to a large capacity

drainage bag via a wide flexible connector tubing. The retention cuff (blue connector) is inflated with water, after insertion of the catheter,

to provide retention of the catheter in the rectum. A flush/sample port is located on the drain tube and provides access for catheter

flushing and stool sampling. If stool is not flowing into the catheter, irrigate the catheter. Fill the Luer syringe with

water, connect the syringe to the clear connector (IRRIG), and slowly depress the plunger.

Alert: Verify connection to correct catheter connector.

Precautions during use If patients develop rectal bleeding, assess for pressure necrosis from the catheter then

discontinue use. Patients with weak sphincter function may expel the catheter or may have increased

leakage of stool. Do not insert anything into the anal canal with the catheter such as suppositories or

thermometers. Do not allow ointments that contain petroleum (e.g. Vaseline®) to come into contact

with the catheter as they may damage it. The following adverse events may be associated with the use of any rectal device:

o infectiono leakage of faecal contento perforationo pressure necrosiso obstruction or loss of sphincter tone.

Equipment



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Instaflo® bowel management system (Catheter kit which includes silicone catheter, collection bag, inflation syringe, and lubricant)

PPE including gown, gloves, goggles (additional protective equipment may be required for patients with infective faeces)

extra water soluble lubricant yellow contamination waste bag humidified water/sodium chloride 0.9% and plain IV giving set/enteral feeding set for

irrigation of the rectum.

Procedure1. Explain the procedure to the patient, where plausible obtain informed consent, and

provide pain relief if necessary.2. Attend hand hygiene, put PPE on. It is advisable to double glove for the rectal

examination.3. Place patient in left lateral position.4. Examine the rectum for faecal impaction and clear any stool present. Feel for any mass,

lesion or stricture which may preclude the use of the device. Check the length of the anal canal during rectal examination, as this will determine catheter size. Typically, most patients will require a 6cm catheter but a short anal canal will necessitate a 4cm catheter (which must be ordered specifically).

5. Prior to use, verify proper inflation and deflation of catheter cuff and balloon and check patency of the irrigation lumen.

6. Connect end of catheter drain tube to collection bag and twist clockwise to lock in place. Clamp and secure collection bag drain tube. Insert drain plug.

7. Lubricate the end of the catheter well and fold in half.8. Grasp the lubricated catheter directly behind the retention cuff with double lumen

connector tubing oriented anteriorly. At the time of maximum sphincter relaxation, insert the balloon end of the catheter into the distal rectum. Maintain anterior orientation of double lumen connector tubing throughout insertion.

9. Fill retention cuff via blue connector with 35-40mL of water. Disconnect the syringe.10. Confirm catheter is tension free.11. Secure catheter, by anchor straps to the patient’s buttocks (use hydrocolloid strip to

protect skin then use tape to anchor straps).12. Hang catheter bag so that the catheter drain is not twisted or kinked.13. Use sheet clip to secure drain tube.14. If patient’s condition permits, tilt the whole bed slightly upward, as this encourages

drainage by gravity.

Confirming placementTo confirm placement, gently tug and release to seat the cuff.If no noticeable stool is in the fluid draining from the patient, alternately squeeze and release the drain tube to manually douche the patient. This may help break up the large stool piece. Refer to “Tips for Inserting the Instaflo®” to clarify how to irrigate.

The Instaflo® should be flushed at least twice a day.



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1. If tolerated, position the patient’s bed to enable retention of fluid in rectum (i.e. foot end of bed elevated approximately 20-30 degrees. The patient’s head can remain slightly elevated. If using an inflated air mattress, inflate to maximum level. The patient will remain in this position for the duration of the irrigation. Placing the patient in the left lateral position during irrigation may improve fluid retention.

2. Verify that the drainage bag can hold another 2 litres of fluid. If not empty bag prior to commencing irrigation.

3. Fill irrigation bag with 100mL of luke warm water and hang 1 metre above anus.4. Connect irrigation bag administration set (IV giving set) to white capped clear connector.5. Open flow control valve on irrigation bag and allow fluid to drain by gravity into the

rectum and colon.6. Open flow valve on irrigation bag and allow fluid to drain by gravity into the rectum and

colon. If fluid leaks around the tube, gentle traction on the drain tube may reduce leakage. If leakage persists, check the retention balloon (BLUE connector) volume and add another 10mL of air to the retention. Do not exceed 40MLS.

7. If possible leave the irrigant fluid in situ and patient in position for 5-10 minutes.8. Connect syringe to the blue connector and completely aspirate the 20mL of air and

allow irrigant to drain.9. After irrigation is complete, disconnect administration set from white capped port and

close cap.10. Return patient to pre procedure position.11. Milk all remaining faeces and irrigant from the catheter.

Ongoing Maintenance1. Strictly adhere to stool modification plan and irrigation protocol.2. Ensure that the tapes are securely attached to patient’s buttocks at all times (white

endotracheal tube (ETT) tape may be tied around the patient’s hips if the buttocks are excoriated).

3. Ensure there is no excessive prolonged traction on the catheter or that the catheter is not occluded due to twisting or patient lying on the tube.

4. Inspect the catheter near the anus to ensure that stool or irrigation fluids are not sitting in the catheter. If present milk the drainage tube.

5. Assess patient’s perineal region for mucous or stool leakage, and clean if present.6. Excessive leakage may be secondary to catheter occlusion with stool. Catheter removal

and reinsertion may be required.7. Flush tubing if required with 50mL of water to prevent faeces building up in the tube.8. Verify retention cuff volume every 7 days by aspirating all of the water from the cuff and

perform a digital examination of the rectum.9. Document observations on GIT tab on MetaVision to ensure continuity of care. 10. Change catheter every 29 days.11. Please see Attachment 2 for trouble shooting ideas if there are any concerns

Catheter Removal1. Explain the procedure to the patient.2. Apply gloves, goggles and gown.



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3. If tolerated, place the patient in a left lateral knee-chest position. Pain relief may be required prior to position change.

4. Deflate catheter retention cuff by connecting syringe to (labelled CUFF) and aspirating all water from retention cuff. Disconnect syringe. Verify deflated state of retention cuff by confirming pilot balloon collapse.

5. Ask the patient to push down gently to expel the catheter.6. If catheter does not come out easily, repeat steps after applying water-soluble lubricant

to anal canal.7. Perform a visual inspection of the rectum post removal.


Evaluation

Outcome CHS staff adhere to the procedures in this document when attending to bowel

assessment and management.

Measures Review of incident reports relating to bowel management. Discussion with clinical staff who are using the document, seek feedback to determine

appropriateness and usefulness of the content.


Related Policies, Procedures, Guidelines and Legislation

Policies Consent and Treatment Policy Patient Identification and Procedure Matching Policy Medication Handling Policy

Procedures Continence Assessment and Management Procedure Autonomic Dysreflexia Procedure Stoma Management – Adults, Adolescents, Children, Infants and Neonates. Infection Prevention and Control – Healthcare Associated Infections Procedure Patient Identification and Procedure Matching Procedure

Guidelines Fasting Guidelines for Patients Undergoing Procedures Requiring Sedation or

Anaesthesia

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004



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Work Health and Safety Act 2011


References

1. Australian and New Zealand Spinal Cord Society (ANZSCOS), September 20102. Chew, S. Peer reviewed Clinical Update: Obstructed Defaecation Australian and New

Zealand Continence Journal, Volume 13 Number 2. 2007.3. Clinical Guidelines for Digital Rectal Examination, Manual Removal of Faeces and

Insertion of Suppositories /Enemas for Adult Care only. NHS.2012. 4. Coggrave, M. Transanal Irrigation for bowel management, Nursing Times. 2007.5. Coggrave, M. Norton, C. The need for manual evacuation and oral laxatives in the

management of neurogenic bowel dysfunction after spinal cord injury: International Spinal Cord Society 48,504-510. 2010.

6. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Neurogenic Bowel Management In Adults with Spinal Cord Injury: Paralysed Veterans of America, Washington. 2010.

7. Emmanuel, A. Review of the efficacy and safety of transanal irrigation for neurogenic bowel dysfunction. International Spinal Cord Society. 48, 664-673. 2010.

8. Furusawa, K. Tokuhiro, A. and Sugiyama, H. Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury. International Spinal Cord Society Cord 49, 49-54. 2011.

9. Goetz, L Transanal Irrigation or conservative bowel for clients with spinal-cord injury? Nature Clinical Practice Gastroenterology & Hepatology (4):256-257. 2007.

10. Treatment Algorithm for Autonomic Dysreflexia (Hypersensitive crisis) in Spinal Cord Injury. 2010. http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#zoom=100

11. Kerr, J (Physiotherapist and Ergonomist). Ergonomic assessment of bowel care management in community setting, 2007.

12. Krassioukov, A. Eng, J. and Claxton, G. Neurogenic bowel management after spinal cord injury. International Spinal Cord Society 48 (10): 718-33. 2010.

13. Management of lower bowel dysfunction, including DRE and DRF Royal Collage of Nursing guidance for nurses 2012.

14. Namirah, J. Zone-En, L. and Olden, K. Diagnostic Approach to Chronic Constipation in Adults. American Family Physician. 2011. www.aafp.org/afp

15. National Guideline Clearinghouse, Practice Guidelines for the Management of Constipation in Adults. 2010.

16. Norton, C and Chelvanayagam, S. (2004) Bowel Continence Nursing. Beaconsfield Publishers, Ltd., U.K.

17. Queensland Spinal Cord Injuries Service: Bowel Management Following Spinal Cord Injury. 2012.

18. Rogers, J. How to manage chronic constipation in adults. Nursing Times: 108 (41): 12, 14 16. 2012.

19. St. Mark’s Hospital and Academic Institute Bowel Control. Constipation. 2010.



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20. The Joanna Briggs Institute. Management older Constipation for Older Adults. Best practice Vol 12(7):1- 2008.

21. McWilliams D, 2010, Rectal irrigation for patients with functional bowel disorders, Nursing Standard Vol 24, No 26 March.

22. Sutcu, S. The prevention and management of faecal incontinence. (2007). The Journal of Stomal Therapy Australia. (27)4. 10-11. Retrieved from: http://www.stomaltherapy.com/documents/JSTA_December_2007.pdf

23. Zassi, Bowel Management System (2003) Instructions for Use, Fernandina Beach, USA.24. The Royal Children’s Hospital Melbourne Clinical Guidelines: Bowel washout (Rectal).

http://www.rch.org.au/rchcpg/index.cfm?doc_id=9220. 17th October 2011.25. National Health and Medical Research Council – Nutrient Reference Values for Australia

and New Zealand (2006).


Definition of Terms

Valsalva manoeuvre: Holding the breath and forcibly trying to exhale against a closed glottis, thereby creating raised intra-abdominal pressure and a bearing-down effect.

Hirschsprung’s Disease: A rare disorder of the bowel, most commonly of the large bowel (sometimes called megacolon), where there is a lack of nerves, known as ganglion cells in the bowel wall. This prevents effective peristalsis and results in intestinal obstruction. It affects four times as many boys as girls with an increased incidence in infants with Down Syndrome.

Meconium plug: This condition is the most common and mildest form of mechanical distal obstruction of the newborn. Inspissated and immobile meconium causes a transient form of distal colonic or rectal obstruction. The aetiology of this disorder is unclear. It is most common in preterm infants.

Meconium ileus: The obstruction is mainly caused by thick tenacious meconium. This stick meconium is unable to be propelled through the intestine, usually the gut is not damaged and continuity is not disrupted. Meconium ileus occurs in 15% of infants with Cystic Fibrosis. In others the condition is associated with volvulus, atresia or perforation.


Search Terms

Bowel, Bowel washout, Rectal administration, Enema, Suppository, Flatus tube, Manual evacuation, Instaflo, Bowel protocol, Intensive Care Unit, Instaflo


Attachments



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Attachment 1: Bristol Stool ChartAttachment 2: Instaflo® troubleshooting guide

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 11/11/2020 Complete Review Linda Kohlhagen, ED

RACSCHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS15/051 Bowel Assessment and Management (Adults, Children, Infants and Neonates)



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Attachment 1: Bristol Stool Chart



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Attachment 2: Instaflo® troubleshooting guide

PROBLEM POSSIBLE CAUSES INTERVENTIONLeaking around catheterduring irrigation

Poor patient positioning

Poorly inflated retention cuff

Position patient such that gravity and colonic anatomy facilitates the flow of irrigant into the patient, (i.e. supine with slightly head down and/or slightly tilted to the left) and the drainage of irrigant and faeces out of the patient, (i.e. supine with slight head up).

Apply gentle traction to “seat” the retention cuff on the rectal floor.

Add additional 10ml water to retention cuff.

Remove added water after irrigation.

Volume of stool in rectum close to defecatory response trigger. Upon initiation of irrigation the defecatory response is triggered resulting in the relaxation of anal sphincters and rectal contraction.

Faeces too firm Deflate intraluminal balloon and aggressively douche to break stool up in the rectum.

Additional irrigant may have to be infused to facilitate douching.

Reactive contraction of the rectum/colon from irrigation that is infused too rapidly, is too voluminous, and/or is too cool. This may or may not be associated with patient cramping

Too cold or too rapid rectal infusion

Optimise rate, volume and temperature of irrigation.

Little or no sphincter Completely deflate retention cuff and re-inflate with 50mL of water (following irrigation, completely deflate retention cuff and re-inflate with 35mL to 40mL of water).

Lack of faecal drainage and/or faecal leakage around catheter

Manage small volume perianal mucous or faeces leakage with routine hygiene and absorbent pads.

Intralumenal balloon is inflated. Transphincteric zone tubing is twisted.

Deflate intralumenal balloon.

Straighten tube and stabilise catheter with anchor straps.

Check for anterior positioning of triple lumen connector tubing.

Proper catheter orientation is required to use anchor straps.



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PROBLEM POSSIBLE CAUSES INTERVENTIONStool is occluding catheter. Instil 300 – 500mL of lukewarm

irrigant with intraluminal balloon deflated and douche until significant amounts of stool begin to exit catheter. Additionally irrigation may be required to clear rectum of stool.

Check stool consistently.

More aggressive stool modification plan/irrigation protocol or catheter removal may be required.

Odour Stool may be accumulating in catheter too long.

Rinse catheter more frequently.

Expulsion of catheter Application of too much traction (tube is pulled out of patient).

Verify no external traction is being applied to catheter (e.g. unsupported weight of collection bag, catheter caught, fit is tension free (1cm or more gap between anchor strap faceplate and anus).

Reduce the amount of traction applied during irrigation.

Little or no sphincter tone. After rinsing catheter, reinsert (per instructions for use) and inflate retention cuff with 40mL of water.

Volume of stool in rectum trigger defecatory response resulting in relaxation of sphincters, rectal contraction and catheter expulsion.

Perform rectal exam to verify no impaction or stool is present in the distal rectum.

After rinsing catheter, reinsert (per instructions for use).

Irrigate the rectum with intraluminal balloon deflated and aggressively douche during irrigation to clear rectum.

Check stool consistency.

More aggressive stool modification plan and irrigation may be required.



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