Bowel care routines after spinal cord injury must be established and tailored to patients’ individual needs. Policies and procedures need to be regularly reviewed
This case study explores the problems that can occur when patients receive ineffective bowel care following spinal cord injury. It also investigates the implications of using anal irrigation for specialist and generalist nurses, education and audit.
Peter Spencer (not his real name) is 28 years old and sustained an incomplete severing of his spinal cord at the sixth thoracic vertebra (T6) following a motorcycle accident, and was cared for in the rehabilitation ward of the local general hospital.
The district nurses were contacted less than a week before his discharge date and a junior nurse attended his discharge planning meeting. Bowel care in hospital had been ineffective and there were unrealistic expectations of the care that could be provided at home.
In hospital Mr Spencer had one glycerine suppository inserted at 8pm. He was often faecally incontinent and frequently required phosphate enemas to treat constipation.
The aims of effective bowel management are to “achieve regular, predictable emptying, at a socially acceptable time and place, avoiding constipation and unplanned evacuations” (Coggrave et al, 2009) Phosphate enemas are not recommended for people with spinal cord injury (SCI) because they cannot be retained, can cause trauma to the rectum and can trigger autonomic dysreflexia (see Box 1) (Coggrave et al, 2009).
When independent bowel care is not an option, plans for community management should be established before discharge (Coggrave et al, 2009) and should be acceptable to patients and be sustainable. Mr Spencer’s hospital care plan failed to maintain continence and could not be sustained following discharge as the PCT evening nursing service only covered emergencies and.
I was asked to visit Mr Spencer at home, to advise on bowel care and to mediate between him and the district nurses. He experienced some altered, unreliable sensation of a loaded rectum when it was empty. This led to conflict with the nurses as Mr Spencer often asked for extra home visits to manage his bowel function that the nurses saw as unnecessary.
Conservative bowel management (Coggrave et al, 2006) was unsuccessful and did not adhere to care recommended by most spinal units. Usual bowel management is described in Box 1.
Care issues after discharge
After discharge Mr Spencer’s bowel care was changed to 8.30am to link with his personal care staff. He frequently had a sensation of a full rectum and often had episodes of faecal incontinence in the afternoon. This affected his quality of life and his faith in the nursing staff, who in turn appeared to resent the amount of time it took to manage his bowels. There were also manual handling issues as he needed twoand a hoist to transfer.
Digital stimulation was attempted but it was time consuming, with bowel care taking up to one and a half hours, with frequent call backs later in the day. Mr Spencer was also embarrassed as he often had an erection during these procedures. Suppositories were replaced by a Microlax enema (Coggrave et al, 2009), and a stimulant laxative in the evening (Coggrave et al, 2009) but this was ineffective. There is evidence that these conservative measures can have a negative impact on quality of life if bowel management is ineffective or time consuming (Glickmann and Kamm, 1996).
After careful consideration a trial of an anal irrigation product (Peristeen) was suggested. This product is designed to facilitate anal irrigation, either by the user or carer, using a hand pump instead of gravity (Coggrave and Norton, 2009). Having achieved positive results with another patient, I felt it might improve Mr Spencer’s bowel care.
Anal irrigation is a recognised management technique used after conservative therapies have failed but before considering National Institute for Health and Clinical Excellence, 2007). It involves passing water through a catheter into the bowel via the anus in a sufficient quantity to reach beyond the rectum (Coggrave, 2008). Christensen et al (2006) compared the anal irrigation system with conventional therapies and found constipation and faecal incontinence decreased while quality of life scores improved in patients with SCI. The least mobile group appeared to have the best results. In the trial only seven out of 42 patients withdrew from the irrigation group – this was because they disliked it, had problems with catheters or found it ineffective.(Royal College of Nursing, 2008;
The procedure is thought to have a low level of risk but inflating the balloon that retains the rectal catheter in place may carry slight risk of perforation (Coggrave and Norton, 2009).
Mr Spencer watched a patient information DVD and identified with the paraplegic person who said he could cope with loss of mobility but not loss of bowel continence. He wanted to try it so I wrote to his GP for agreement and arranged training for the district nurses.
Mr Spencer has now used anal irrigation for 18 months, with only three episodes of faecal incontinence. He still has sensations of rectal fullness but has learnt to ignore these. He attends the gym regularly and is in the process of setting up his own computer repair business. He said he would never have been able to do this if he did not have confidence in his bowel care.
The problems between Mr Spencer and the district nurses began as a result of poor discharge planning. He called the community nursing staff about bowel care several times during the day and was labelled as demanding and unpopular. It is always important to consider patients’ needs and share decision making. Mr Spencer was a young man who had lost his independence, had spent 18 months in hospital after a devastating accident and had many reasons to want support and reassurance.
Norton and Chelvanayagam (2004) discussed the low status of bowel care and the disgust nurses have to overcome when dealing with faeces. Even in SCI units there may be reluctance to discuss bowel care and it is seen as a low priority (Coggrave et al, 2006). People with incontinence are often labelled as unpopular (Stockwell,1972) and this view may be passed on during nursing handover, particularly to junior staff (Williams, 2007). Those staff who got on well with Mr Spencer were the experienced confident nurses, while those who did not seem to enjoy caring for him were junior and less confident staff.
Role modelling is a key element of leadership (Jarman, 2007) and the community team leader rarely visited Mr Spencer. This could be compared with another community team who had recently had a person with an SCI discharged from hospital. The team leader was proactive in arranging care, attending the bowel care course to update her skills and ensuring all her team were competent. I had to take on the role of team leader and became actively involved in motivating and training staff,
Introducing anal irrigation
Training and support were arranged for staff undertaking the procedure but an up to date bowel policy incorporating anal irrigation was also needed to ensure their practice was standardised and at an appropriate level.
The three continence services across the local health community have worked collaboratively for the last five years to develop joint care pathways, product provision guidelines, training programmes and policies. A bowel policy was being written but was taking time to complete so a local interim policy was drawn up.
As part of the policy patients must give written consent for treatment as the procedure is defined as complex by the PCT. As part of the policy review we noted that we needed to include management of autonomic dysreflexia. A suitable policy was identified during an internet search and permission was received for this to be adopted locally.
Procedures for introducing new technologies
The PCT’s risk and governance committee now has a protocol for introducingand methods of care and a submission has been made retrospectively for anal irrigation. This protocol ensures that staff training and patient monitoring using anal irrigation is ongoing. It also specifies that this form of bowel management should not be considered until conservative measures have been tried, and specifies what information patients should be given. It ensures that all patients who use this procedure do so under guidance from the continence service.
Anal irrigation offered Mr Spencer the best option for bowel care, reduced his faecal incontinence and constipation, the time spent on bowel care and improved his quality of life. It is important that policies and procedures are reviewed when new technology or treatment is introduced and staff receive adequate training and support.
Box 1. Bowel management following spinal injury
Low spinal injury (lumbar vertebra 1 to sacral vertebra 5) causes a flaccid bowel and is likely to require stimulant laxatives and digital removal of faeces (Coggrave et al, 2009; Ash, 2005).
Higher injury (T12 or above) causes a reflex bowel. This can be stimulated mechanically or chemically, to trigger distension of the anal sphincters, and initiate (but not delay) defecation. Coggrave et al (2009) suggested that digital removal of faeces is often required to complete the evacuation.
Conservative management of bowel care includes:
• Assessment of diet and fluid intake;
• Making use of the gastrocolic reflex – initiating bowel evacuation soon after food or fluid ingestion;
• Abdominal massage;
• Digital stimulation.
If these measures are unsuccessful, manual removal of faeces may be required, with oral or rectal stimulants (Coggrave, 2008). However, there is little evidence to support these strategies (Coggrave et al, 2009).
Autonomic dysreflexia is an abnormal response to pain or other noxious stimuli in patients with an injury at T6 or above resulting in a potentially life threatening rise in blood pressure (Wiesel and Bell, 2004). It can be caused by constipation and bowel care and symptoms include severe acute headache, bradycardia, bronchospasm, blurred vision, chills and sweating. Treatment includes elevating the head, reducing the blood pressure and removing the stimuli (Grundy and Cumming, 1996).
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Catherine Williams, BSc Nursing, RGN, DipHE, DN, is continence service manager, NHS North Somerset Community Services, Pill, Somerset