•
Spinal Neurogenic Bowel
Nursing Issues
SCI and Defaecation
•
Level and completeness of SCI affects amount of control
& determines which bowel care method will work.
•
Impacts on gastric emptying time, colonic transit time &
whole gut transit time, anal sphincter tone, pelvic floor
functioning
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Sitting balance, upper limb function & transfers.
AIMS OF BOWEL MANAGEMENT
For the spinal cord injured person to have an individually
tailored bowel plan which is the key for self management
Tailored Bowel plan
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Is reliable, effective, predictable & timely
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Is a bowel program that suits their lifestyle & care routine
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Planned regular emptying to avoid complications, eg
autonomic dysreflexia, constipation &/or diarrhoea,
incontinence
Acute - Spinal Shock
Initial bowel management following SCI:
•
Observe for onset of paralytic ileus
•
Daily assessment of bulbocavernosus reflex
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Nil by Mouth with nasogastric tube until bowel sounds return
•
IV therapy to maintain hydration
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Check rectum for presence of stool on a daily basis
•
Gently remove stool using water-based lubricated gloved
finger
Acute - Spinal Shock
Commencement of bowel management occurs when bowel
sounds have returned & flatus passed. Gradual
introduction of fluids & diet
 Perform daily PR check & manual evacuation as needed.
 Tolerance of extended sitting periods for bowel care,
routine based on level of injury (functional & type of bowel
(UMN or LMN
Long Term BOWEL MANAGEMENT
FIVE ‘Rs’ OF BOWEL MANAGEMENT
 right time
 right amount
 right place
 reliable trigger
 right consistency
Long Term BOWEL MANAGEMENT
Factors to take into account for all individuals:
• Type of bowel dysfunction : UMN or LMN
• History of previous bowel habit and trial of previous bowel regimes
• Co-morbid pathologies of GIT, haemorrhoids, anal fissure, etc
• Medications & side effects
• Functional ability, mobility, transfers, sitting balance, arm reach &
hand function
• Cognitive ability
• Diet, fluid intake, food preferences, activity/exercise, lifestyle
motivation, problem solving skills
Upper Motor Neurone BOWEL MANAGEMENT
Above T12 (Reflex bowel)
– Plan a daily routine to begin, with view to 2nd daily, which mimics
previous habit
– Regular aperients: coloxyl – 50mg BD, Senna 8 to 12 hrs prior to
supps & at same time each day
– Plan bowel emptying 20 – 30 minutes after food or drink (use
gastrocolic reflex)
– PR meds daily but at same time each day - 1-2 Bisacodyl
suppository
– Consider anal (digital) stimulation/ relaxation
– Type 4 Bristol Stool Scale
Lower Motor Neurone BOWEL MANAGEMENT
T12 and Below (Flaccid Bowel)
– Plan Daily or BD routine
– Oral aperients ie. Coloxyl BD and Senakot nocte taken at the
same time each day
– PR Meds once or twice daily but at same time: 1 microlax
enema. Squeeze contents of enema into Rectum from base
of the container to prevent back flow.
– Type 3 Bristol Stool Scale
– May need to do manual evacuation
Anal Relaxation/ Stimulation
– insert a well lubricated gloved finger to first joint into rectum
to “tickle” until you feel the anal sphincter relax.
– move the finger GENTLY in a sweeping motion to relax the
anal sphincter.
– stimulate for 20 seconds & no longer than 1 minute. Repeat
every 5 to 10 minutes.
– No more than 5 stimulations should be required
– observe for signs of spasm, dysreflexia or bleeding
Trouble Shooting
• GOLDEN RULE :
CHANGE ONLY ONE THING
AT A TIME
• allow at least 3-5 bowel cycles to
establish effect of change
Autonomic Dysreflexia due to bowel
Treatment
• PR WITH WELL LUBRICATED GLOVED FINGER.
• If rectum full, check BP. If BP >150 mm Hg.
• Call ambulance.
• Start Antihypertensive medication – Nitrolingual spray or
Anginine. DO NOT use glyceryl trinitrate if Viagra or Levitra has been taken in previous
24 hours or Cialis in the previous 4 days
• Gently insert a generous amount of lignocaine gel into the rectum
and gently remove the faecal mass. If BP increases stop
immediately
References
• Pryor J, Fisher M, Middleton J. Management of the Neurogenic Bowel for
Adults with Spinal Cord Injuries. Chatswood NSW: Agency for Clinical
Innovation. 2014. Website: http://www.aci.health.nsw.gov.au/
• Coggrave M, Norton C, Cody JD. Management of faecal incontinence
and constipation in adults with central nervous diseases. Cochrane
Database of Systemic Reviews. 2014.
• Solving common bowel problems: A resource tool for persons with spinal
cord injury.
Website: www.continence.org.au
• Queensland Spinal Cord Injuries Service: Fact Sheet Bowel
Management following Spinal Cord Injury 2014
www.health.qld.gov.au/qscis