When spinal cord injury affects the bowel

Published: January 12, 2004
1910

Neurogenic bowel is a frequent problem for patients with spinal cord injury. With planning and care, however, you can help them regain control over their bowel function. Here’s how.

Damage to the spinal cord leaves patients at risk for a number of complications. A common one is neurogenic bowel–a condition in which the patient has no voluntary control over stool elimination.

Two types of neurogenic bowel affect patients with spinal cord injury: reflexic and areflexic. Reflexic, or upper Motor Neuron, bowel occurs when damage to the spine is above T12. In patients with reflexic bowel, anal reflexes are intact and can be stimulated to prompt defecation.

In contrast, patients with areflexic, or lower motor neuron, bowel–have lesions at or below T12. They have no Sacral Reflex arcs that can be stimulated to cause bowel movements.

On a personal level, the loss of bowel control causes embarrassment, even humiliation. Clinically, neurogenic bowel can lead to more serious problems, including bowel obstruction, colorectal distention, bleeding hemorrhoids, and diverticulosis. It can also elicit Autonomic Dysreflexia, an exaggerated and life-threatening sympathetic response most often triggered by a distended bladder or bowel.

Fortunately, there’s a way to reduce the occurrence of involuntary stool elimination by patients with spinal cord injury. As the provider most intimately involved in your patients’ care, you are in an ideal position to develop a bowel management program–also known as an assisted defecation procedure–which will help put your patients back in control of one of their most basic bodily functions.

Key elements in effective bowel care

Ideally, a bowel management program should be initiated in the acute care setting once the patient’s spinal cord injury and associated medical conditions are stabilized and bowel sounds have returned. [1] Before beginning, the nurse–with the help of the patient, his family, and other members of the healthcare team–will need to address a variety of factors to ensure that the program is a success.

Timing and consistency. Because your goal is to have the patient defecate at predicted times, bowel movements should be scheduled for the same time of day at regular intervals–initially once a day. [2] Ultimately, you will want to mimic, as closely as possible, the patient’s elimination schedule before his injury–whether that was three times a day or three times a week.

If your patient needs assistance with bowel care–if he has Quadriplegia, for example–set up a schedule that allows him to have a bowel movement at a time when a caregiver or family member is available to help him.

Diet and fluid intake. To help prevent diarrhea and constipation, it’s important that you help your patient select menus that contain foods with fiber, such as whole-grain breads and cereals, leafy vegetables, legumes, nuts, and fresh fruit. [1,3] Fiber helps create soft, bulky stool, which can pass through the intestines without delay. [1]

Although clinicians frequently recommend high-fiber diets (20 – 30 gm a day) for patients with spinal cord injury, clinical practice guidelines released by the Consortium for Spinal Cord Medicine in 1998 state that patients with neurogenic bowel may not respond well to that much fiber. [2] The Consortium recommends at least 15 gm of fiber each day but also advises clinicians to take into account the amount and consistency of the patient’s stool and adjust the diet accordingly. [2]

Ensuring that the patient drinks enough fluid helps prevent constipation and impaction. [2] Encourage him to keep a record of the amount of fluids he drinks each day. Depending on the prescribed bladder care program, patients should drink 2-3 liters a day. [3] To determine the amount of fluid your patient needs, use this formula: 40 nil/kg of body weight + 500 ml. [2]

Medication use. The typical Bowel program includes the use of stool softeners and laxatives. At my facility, patients receive 50 mg of docusate sodium (Colace, Doxinate, Modane Soft) once or twice a day depending on the consistency of their stool. They are also given 187 mg of senna (Senokot, Senolax) eight to 12 hours before their scheduled bowel movement; it helps move stool to the lower bowel so that it can be evacuated. [1]

Because other medications, such as antibiotics and iron supplements, may adversely affect bowel function, adjust the patient’s laxative use or diet to compensate for the side effects of these drugs. [1] In the case of antibiotics, ask the dietitian to include active yogurt in the patient’s meals; it helps restore normal bowel flora. [4]

The basic steps of a bowel program

The patient should start out with a clean bowel. At my facility, we use enemas to accomplish this the day before we begin the program. [2]

The program starts out in the same way whether the patient has reflexic or areflexic bowel. Begin by having the patient drink a cup of hot tea, coffee, prune juice, or water with lemon about a half hour before the scheduled bowel movement. As the hot fluid enters the stomach, the gastrocolic Reflex stimulates peristalsis, forcing stool toward the anus.

Use a bisacodyl (Dulcolax) or glycerin suppository 20 – 30 minutes later: Have the patient lie on his left side–a position that will help ensure that the suppository is placed securely in the rectal vault. Tell him to take deep breaths, which may help to relax the sphincter. Don gloves; then, using a water-soluble lubricant like K-Y jelly, insert the suppository about 1 1/2 – 3 inches past the internal sphincter with your index finger. The suppository must be in contact with the rectal mucosa to be effective.

Wait 20 minutes, and then transfer the patient to the toilet or bedside commode, if he can tolerate it. If there’s no response after 10 minutes, transfer him back to bed.

The steps you take next will depend on the type of neurogenic bowel your patient has. If it’s reflexic, perform digital stimulation: Using gloves and lubricant, insert your finger into the rectum and move it in a slow, circular motion-slightly stretching the sphincter. Continue this motion for at least 15 seconds or the length of time specified by your facility’s procedure manual, but no longer than a minute. [2]

Remember that a patient with a spinal cord Lesion above T6 (and some with lesions as low as T8) is at risk for Autonomic Dysreflexia, which may be triggered by a noxious stimulus, such as your finger, below the level of the lesion. In these cases, apply an anesthetic ointment such as lidocaine (Xylocaine) 10 minutes before the suppository or digital stimulation. [5]

Because digital stimulation will not work for the patient with areflexic bowel, you’ll need to try a different tactic. If there’s no response to the suppository, have him turn onto his right side. In this position, gravity helps the stool into the rectum. Having him wear an Abdominal Binder, which applies pressure to the bowel area and decreases the risk of hypotension, may also help.

When the patient is ready to defecate

Following these steps should help your patient have a bowel movement at a scheduled time. One sign that he is ready is the passage of flatus. [6]

Have him sit with his feet elevated so that his knees are slightly higher than his hips. This position increases abdominal pressure and facilitates stool passage. If possible, he should lean forward; he can lean on an over-the-bed table placed in front of him, but make sure the wheels are locked so it doesn’t roll.

Because patients with spinal cord injury often have Spasticity and are at risk for falling, use safety straps, padding, and pillows to position and support them. If the patient is using a bedside commode, lock the wheels. Also place a gait belt around him and attach it to the commode.

Some patients may not be able to tolerate a sitting position. If that’s the case, defecation will have to take place in bed. The use of bedpans and diapers is discouraged, because it can contribute to pressure ulcer formation. [2] Use plastic bed protectors and absorbent pads, instead.

Because stool elimination is a personal matter, respect your patient’s privacy. If he’s in bed or using a commode, pull the curtain around him. If he’s using the bathroom, close the door. Make sure the call bell or a hand-held bell is within reach so he can signal you if he needs help. If he can, have him massage his abdomen in a clockwise motion, going up the right side, across, then down the left side; this technique increases abdominal pressure, thereby aiding stool elimination.

Also remember to provide scrupulous skin care–cleansing the patient with water and the perineal care product used by your facility.

Initially, the entire bowel management program may take up to two hours to complete. If no bowel movement occurs, you may have to remove the stool manually. Don’t give up on the program, even if the patient has an episode of Incontinence. Try it again at the next scheduled interval.

Helping maintain lifelong regularity

Establishing a successful bowel management program can take as little as two weeks or as long as several months. Thorough assessment and documentation of every aspect of your patient’s bowel care–from the timing of the scheduled bowel movement and medication use to the color, consistency, and amount of stool–will help you determine if the program is working.

If the patient develops problems such as constipation or unplanned bowel movements, adjust the program by, say, modifying ins diet. Make one change at a time, then wait about three days to see if there’s an effect.

If the patient is able to have bowel movements on a regular basis for at least three cycles, consider simplifying the process. Eliminate one drug at a time and wait a few days to assess the effect. The ultimate goal is to have the patient defecate at a predictable time with only a suppository or, in the case of a patient with reflexic bowel, digital stimulation.

Before the patient is discharged, make sure he or ins caregivers understand and are able to perform each step of the program. Document your teaching and their demonstrated ability in the chart.

Also be sure that they obtain, and have demonstrated their ability to correctly use, the necessary devices and equipment–a suppository inserter, a digital stimulator, or a roll-in shower or commode chair, for instance. Any item that needs assembly should be delivered to and installed in the home before the patient is discharged.

Suggest ways that the patient and the family can adapt the program once they’re home. For example, they don’t absolutely need latex gloves for inserting the suppository; plastic wrap wound around the hand works just as well. And, rather than buying plastic bed protectors and absorbent pads, they can use newspapers and plastic bags.

Make sure they know to call the patient’s primary provider if complications arise: diarrhea or constipation over several days, nausea, vomiting, loss of appetite, bloating or distention, rectal bleeding, a rigid abdomen, or increased flatus.

Last but not least, stress the importance of strictly adhering to all aspects of the prescribed Bowel program. Making changes without consulting a healthcare provider could result in uncontrolled bowel movements. Surely, after all the hard work, that’s one outcome no one wants.

GAIL BRYANT was a night charge nurse on the inpatient Rehabilitation unit at St. Vincent Hospital in Santa Fe, N.M. at the time this article was written. She has since retired.

REFERENCES

(1.) Hoeman, S. P. (1995). Rehabilitation nursing process and application (2nd ed.]. St Louis: Mosby.

(2.) Consortium for Spinal Cord Medicine. (1998, March). Neurogenic bowel management in adults with spinal cord injury: Clinical practice guidelines. Washington, DC: Paralyzed Veterans of America.

(3.) Spoltore, T. A., & O’Brien, A. M. (1995). Rehabilitation of the spinal cord injured patient Orthopaedic Nursing, 14(3), 7.

(4.) Elmer, G. W., Surawicz, C. M., & McFarland, L. V. (1996). Biotherapeutic agents: A neglected modality for the treatment and prevention of selected intestinal and vaginal infections. JAMA, 275(11), 870.

(5.) Travers, P. L. (1999). Autonomic Dysreflexia: A clinical rehabilitation problem. Rehabilitation Nursing, 24(1), 19.

(6.) Linsenmeyer, T. A., & Stone, J. M. (1998). Neurogenic Bladder and bowel dysfunction. In J. A. DeLisa & B. M. Gans (Eds.), Rehabilitation medicine: Principles and practice (3rd ed.), (pp. 1073 – 1103). Philadelphia: Lippincott-Raven.

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