BOWEL/BLADDER SCREENING

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Area of Function:

BOWEL/BLADDER SCREENING

Definition

Screen and identify patients with bowel and bladder dysfunction:

Persons with: Impaired mobility Bowel dysfunction Chronic illness Interstitial cystitis Cognitive impairment Psychological dysfunction Stroke

Bowel or bladder incontinence

Complicated bowel/bladder management routines. Psychological dysfunction

Paralytic ileus

Neurogenic bowel or bladder dysfunction Colostomy, Ileostomy, Koch Pouch

Refer patients to primary care givers for further assessment and treatment/intervention. Screening Outcomes

Interdisciplinary team approach

Clients with bowel or bladder dysfunction are identified. Complete Assessment, diagnosis.

Referral to tertiary assessment: bowel or bladder dysfunction specialist, continence advisor, or specialist as appropriate

Assessment

Professionals responsible for screening: Interdisciplinary team members, i.e. Registered Nurses (RNs), Registered Therapists (RTs), Licensed Practical Nurses (LPNs), Occupational Therapists (OTs), Physiotherapists (PTs), Long Term Care Aides (LTCAs), and physicians.

When should the assessment take place?

Within 24 hours of admission to hospital/facility screening of bowel function done through history taking and observation.

Within 1 to 3 days or within the first 3 visits for admission to community care. Timely identification for continence management.

What should a bowel/bladder screening include?

1. Admission history and/or checklist (community); consider admitting diagnosis and resulting pathophysiology. Indicates pre-morbid elimination patterns, risk factors.

Use a Bowel and bladder screening tool which includes:

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2. Assess daily habits – cognition and communication – mobility and environmental issues.

Determines level of awareness and ability to communicate need and/or assist for toileting. 3. Document results in chart:

Timing/frequency of stools/amount. Timing/frequency of voiding/volume

Circumstances associated with incontinence.

Admission record, progress notes, physicians’ progress notes.

4. Constipation and/or dysfunction/incontinence noted in history or clinical observation indicates need for further assessment, diagnosis and plan of care.

Nursing to complete detailed history.

Physical, functional and environmental assessment. Perform rectal exam as indicated.

Physician to perform history and physical exam and order investigations as indicated. References

1. National Institute of Neurological Disorders and Stroke:

2. www.ninds.nih.gov/health_and_medical/pubs/poststrokerehab.htm 3. Nursing 2002, 32 (11) Pg. 54

4. Juan de Fuca Bowel and Bladder Management Manual, J. Mantle 5. Bladder Health in Rehabilitation – A Self Learning package for Nurses

6. British Journal of Nursing 2001: Devising an Effectual Clinical Nursing Continence Assessment Tool.

7. Chraska K., Van Dyke K., Bertholin B.; “Rehabilitation Nursing Course Syllabus” 1990 edition, revised April 1995

8. Managing Acute and Chronic Urinary Incontinence: Quick Reference Guide for Clinicians, March 1996 9. Martin N., Holt N., Hicks D.: Comprehensive Rehabilitation Nursing 1981, 14 Urinary Function

10. Rehabilitation Nursing: Concepts and Practice, A Core Curriculum 1981.

11. Schultz, J.: “Urinary Incontinence – Solving a Secret Problem” Nursing 2002, November 02 12. Medical Care of the Dying, 3rd Edition, Victoria Hospice Society.

13. Rehabilitation Nursing; Concepts and Practice, A Core Curriculum, 1981 14. Seniors Health Bowel Care Program – A Study Module for Nurses

15. _{Wikander, B., Ekelund, P., & Milsom,I., (1998). An Evaluation of Multidisciplinary Intervention Governed by}

Functional Independence Measure (FIM) in Incontinent Stroke Patients. Scandinavian Journal of Rehabilitation Medicine. 15-21.

16. Folden SL, Backer JH, Maynard F, Stevens K, Gilbride JA, Pires M, Jones K. Practice guidelines for the management of constipation in adults. Glenview (IL): Association of Rehabilitation Nurses; 2002. p. 51

17. Parkland Rehabilitation Hospital: Evidence-based Review of Stroke Rehabilitation

Appendices

1. Seniors Health Bowel Care Program – A Study Module for Nurses

(This Module is available electronically if requested) Page 6: Constipation: Framework for Clinical Decision Making

Page 7: Impaction: Framework for Clinical Decision Making Page 31: Assessment

Page 21: Constipation: Assessment

2. Seniors Health Bowel Care Program Appendices: Appendix C: Bowel Assessment Sheet

Appendix E: Clinical Practice Guideline: Impaction. Appendix I: Bowel Care Audit Tool

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BOWEL ASSESSMENT

Definition

Primary care providers, i.e. Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Long Term Care Aides (LTCAs), Occupational Therapists (OTs), Physiotherapists (PT)s and physician(s), will assess a patient identified with bowel dysfunction through screening.

Determine elimination patterns and dysfunction. Assess risk and/or contributing factors.

Perform physical exam, order investigations. Review current medications.

Assess mobility and safety

Recommend/develop incontinence management plan.

Assessment

1. Identify symptom patterns of elimination utilizing the Bowel Assessment tool_{(Appendix C – Seniors Health Bowel} Care Program).

Determining elimination pattern will assist with treatment plan or management options. 2. As per the Bowel Assessment tool assess risk and/or contributing factors.

Identify amount/type of daily fluid intake. Identify daily intake of dietary fiber. Mobility/transfers, need for aids Level of alertness, cognitive status. Fecal impaction.

Environmental barriers/clothing

Pre-existing medical issues e.g. stroke, diabetes, depression, diverticulosis, hemorrhoids, etc. Lack of privacy, poor position during defecation.

Ability to physically wipe self, adjust clothing.

3. Physical exam/testing to rule out infection/pathophysiology.

Nurse to perform inspection, palpation and auscultation of abdomen, rectal exam. Physician to perform physical exam including abdominal, rectal exam.

Order stool exams, relevant lab work. Medical imaging if indicated.

4. Review current medications.

Analgesics, narcotics, anti-depressants, iron preparations, diuretics affect bowel function. 5. Document findings and recommend/develop continence management plan:

Chart on progress notes, bowel assessment record. History and physical progress notes.

Physician’s progress notes.

Involve patient/family/caregiver in goal setting/treatment options. Safety, independence, hygiene and transfers.

References

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15. _{Wikander, B., Ekelund, P., & Milsom, I., (1998). An evaluation of Multidisciplinary Intervention Governed by}

Functional Independence Measure (FIM) in Incontinent Stroke Patients. Scandinavian Journal of Rehabilitation Medicine. 15-21.

BLADDER ASSESSMENT

Definition

Primary care providers, i.e. Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Long Term Care Aids (TCAs), Occupational Therapists (OTs), Physiotherapists (PTs) and physician(s), will assess a patient identified with bladder dysfunction through screening.

Determine voiding patterns and dysfunction. Assess risk and/or contributing factors. Perform physical exam, order investigations. Review current medications.

Outcomes

Identification of bladder dysfunction Identification of patient learning needs Interdisciplinary team approach

Recommend/develop incontinence management plan. Assessment – Using Bladder Assessment Tool

• Identify symptom patterns for stress, urge, mixed, overflow and functional incontinence. Determining voiding pattern will assist with treatment plan or management options. • Assess risk and/or contributing factors.

Identify amount/type of daily fluid intake. Tobacco, caffeine use.

Mobility/transfers, need for aids. Level of alertness, cognitive status. Environmental barriers/clothing

Pre-existing medical issues e.g. diabetes, stroke, estrogen depletion, interstitial cystitis, neurogenic bladder, and pelvic muscle weakness/prolapse in woman or prostate enlargement in men.

Independence with hygiene

OT/PT to assess patient’s safety in independence with toilet transfers, clothing adjustments and other compensatory strategies to assist with elements of their environment that limit activities.

• Physical exam/testing to rule out infection/pathophysiology.

Nurse to palpate and inspect abdomen, inspect external genitalia. Physician to perform physical exam including abdominal, rectal exam.

Order PVR scan and/or catheterization, urinalysis, culture, relevant lab work (CBC, elec, BUN, creatinine). Medical imaging as indicated.

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• Review current medications.

Brisk diuresis induced by diuretics may precipitate incontinence.

Anti-cholinergics, psychotropic drugs, calcium channel blockers, etc. may cause or aggravate incontinence. • Document findings and recommend/develop continence management plan.

Chart on MDP progress notes, bladder assessment record. History and physical progress notes

Physician’s progress notes.

Involve patient/family/caregiver in goal setting/treatment options. References

11. Schultz, J.: “Urinary Incontinence – Solving a Secret Problem” Nursing 2002, November 02 12. Medical Care of the Dying (1998) 3rd Edition, Victoria Hospice Society.

15. Wikander, B., Ekelund, P., & Milsom,I., (1998). An evaluation of Multidisciplinary Intervention Governed by Functional Independence Measure (FIM) in Incontinent Stroke Patients. Scandinavian Journal of Rehabilitation Medicine. 15-21.

BOWEL MANAGEMENT

Definition

Bowel management is defined as the client/patient achieving regular bowel evacuation on a regular time schedule: Involving and educating the patient/family/caregiver in the bowel program.

Establish regular bowel movements to facilitate independence and health with the least amount of intervention, expense and assistance of others.

Prevention of complications. Based on a thorough assessment.

Where possible, discharge planning and follow-up for management at home as needed will be implemented Care Outcome:

Examples/goals are based on best practices and are evidence based. Prevent complications of the bowel by:

Interdisciplinary team approach

Establishing programs for each patient that will minimize complications.

Carefully adhering to established guidelines for avoidance of complications (e.g. principles of asepsis) when carrying out these procedures.

Establish bowel programs that will maximize the client’s ability to function in his or her chosen lifestyle. Promote the patient and primary caregiver’s ability to facilitate the maintenance of a healthy bowel.

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Maintain intact skin integrity

Management of functional incontinence. Achieve regular bowel movements.

Prevent constipation. Refer to a RD for assistance with dietary changes, ways to increase fiber/fluids, etc. Client knowledge of risk factors and methods for preventing constipation.

Establish routine of regular, complete bowel elimination with fewer incontinent episodes or without incontinent episodes.

Management

2. Educate client/patient and family.

Education of basic anatomy and physiology of alimentary canal to gain better understanding of problem. Identify dysfunction specific to patient and explore treatment options available with focus on most acceptable by patient.

For discharge planning, identify needs and refer as needed: community and social supports required for client and family: i.e. Long Term Care, Home Nursing Care, Rehabilitation, Social Work, support groups.

2. Develop plan with client/patient and/or family Institute treatment and/or preventative plan

Have dietician review diet and make changes as needed. Educate staff/team members.

Establish consistent habit time, utilizing gastro-colic reflex, provide privacy and good positioning.

OT/PT to institute safe transfers, evaluate and eliminate environmental barriers, and safety aids as needed. 5. Document effectiveness of plan, problems and client/patient’s response.

Chart on MDP notes, bowel flow sheet. Physician’s progress notes.

Dietician’s record.

Independence and safety during transfers, independence for hygiene. Revise as appropriate.

4. Reassess and revise as required whenever there is a change in bowel function. See Attached Appendices

Seniors Health Bowel Care Program – A Study Module for Nurses

Page 6: Constipation: Framework for Clinical Decision Making Page 7: Impaction: Framework for Clinical Decision Making Page 31 Assessment

Page 21 Constipation: Assessment Seniors Health Bowel Care Program Appendices:

Appendix C: Bowel Assessment Sheet

Appendix E: Clinical Practice Guideline: Impaction. Appendix I: Bowel Care Audit Tool

References

www.ninds.nih.gov/health_and_medical/pubs/poststrokerehab.htm 2. Nursing 2002, 32 (11) Pg. 54

6. Chraska K., Van Dyke K., Bertholin B.; “Rehabilitation Nursing Course Syllabus” 1990 edition, revised April 1995 7. Managing Acute and Chronic Urinary Incontinence: Quick Reference Guide for Clinicians, March 1996

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8. Martin N., Holt N., Hicks D.: Comprehensive Rehabilitation Nursing 1981, 14 Urinary Function 9. Rehabilitation Nursing: Concepts and Practice, A Core Curriculum 1981.

14. _{Wikander, B., Ekelund, P., & Milsom,I., (1998). An evaluation of Multidisciplinary Intervention Governed by}

Functional Independence Measure (FIM) in Incontinent Stroke. Patients. Scandinavian Journal of Rehabilitation Medicine. 15-21.

Parkland Rehabilitation Hospital: Evidence-based Review of Stroke Rehabilitation

BLADDER MANAGEMENT

Definition

Bladder management is defined as the client/patient achieving consistent bladder emptying safely, effectively and completely, i.e.:

Involving and educating the patient/family/caregiver in the bladder program.

Controlled voiding with least amount of intervention, expense and assistance of others. Prevention of complications.

Based on a thorough assessment.

Where possible, discharge planning and follow-up for management at home as needed will be implemented

Care Outcome

Examples/goals based on Best Practices and evidence based. Prevent complications of the urinary tract by:

Interdisciplinary team approach to management

Establishing programs for each patient that will minimize complications.

Carefully adhering to established guidelines for avoidance of complications (e.g. principles of asepsis) when carrying out these procedures.

Establish bladder programs that will maximize the client’s ability to function in his or her chosen lifestyle. Promote the client/patient and primary caregiver’s ability to facilitate the maintenance of a healthy urinary tract. Maintain intact skin integrity

Management of functional incontinence. Management

3. Educate client/patient and family.

Education of basic anatomy and physiology of the urinary tract to gain better understanding of problem. Identify dysfunction specific to patient and explore treatment options available with focus on most acceptable by patient.

Educate staff and team members.

For discharge planning, identify and refer as needed: community and social supports required for client and family: i.e. Long Term Care, Home Nursing Care, Rehabilitation, Social Work, support groups.

2. Develop and implement treatment and/or preventative plan

Ensure participation of client/patient and/or family in development of plan

Establish regular voiding/catheterizations schedule, providing appropriate positioning, and privacy. Evaluate effectiveness of plan

Revise as needed

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Revise plan as appropriate.

References

www.ninds.nih.gov/health_and_medical/pubs/poststrokerehab.htm 17. Nursing 2002, 32 (11) Pg. 54

21. Chraska K., Van Dyke K., Bertholin B.; “Rehabilitation Nursing Course Syllabus” 1990 edition, revised April 1995 22. Managing Acute and Chronic Urinary Incontinence: Quick Reference Guide for Clinicians, March 1996

23. Martin N., Holt N., Hicks D.: Comprehensive Rehabilitation Nursing 1981, 14 Urinary Function 24. Rehabilitation Nursing: Concepts and Practice, A Core Curriculum 1981.

27. Rehabilitation Nursing; Concepts and Practice, A Core Curriculum, 1981

28. Wikander, B., Ekelund, P., & Milsom,I., (1998). An evaluation of Multidisciplinary Intervention Governed by Functional Independence Measure (FIM) in Incontinent Stroke Patients. Scandinavian Journal of Rehabilitation Medicine. 15-21.

See Attached Appendices Bladder Tools

Appendix A: Neurogenic Bladder Dysfunction and Management Appendix B: Management of Urinary Incontinence

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HOME AND COMMUNITY CARE BOWEL ROUTINE

Being constipated is uncomfortable and can make you feel unwell. These guidelines may assist you in preventing this from becoming a problem.

It is not necessary to have a bowel movement every day. As long as your stools are soft and easy to pass, it is okay to have a movement every 2 or 3 days.

SUGGESTIONS FOR RELIEVING CONSTIPATION

1. The strongest bowel movement reflex usually occurs early in the morning; another strong reflex occurs 30 minutes following a meal. In order to use nature to your advantage, try these suggestions:

Upon arising (in the a.m.) drink 1 – 2 cups of warm tea, coffee or water. Have breakfast and your usual breakfast drink.

Try having a bowel movement ½ hour after breakfast (some people are most successful after lunch or supper). Try to establish a routine time.

2. Mobility promotes action of the bowel

Regular, daily exercise as tolerated (e.g. walk) is helpful. 3. A good diet and plenty of fluids are very important:

Increase fluid intake. Aim for 6 to 8 glasses daily. (Sips throughout the day are effective and easier to manage.

Increasing fibre content by 5 grams per day will be helpful. A list of foods that are high in fibre and a “Fruit Lax” recipe are listed below.

Choose plenty of fresh fruits and vegetables. Eat regular, balanced meals

4. Start a habit of recording each bowel movement on your calendar. It is easy to lose track of the days between bowel movements.

5. When nature calls, answer promptly. Delaying a bowel movement may cause a weakening of the reflex act. Comfortable positioning on the toilet is beneficial i.e. having a stool under the feet if necessary.

6. If following a well balanced diet and increasing activity has not prevented constipation, you may require a laxative. Ask your doctor or community health professional for advise in regards to this. As well, your pharmacist has helpful information in regarding laxatives you might choose (some contain sodium, some require lots of water to be effective, some should not be combined with stool softeners).

Some foods that have high fibre content:

All bran - ½ cup 8.5 grams

Bran Flakes, 40%, Kellogg’s - ¾ cup 4.0 grams Raisin Bran, Ralston Purina - ¾ cup 4.8 grams Apple, raw, with skin, - 1 med. 2.8 grams Blueberries, raw – 1 cup 4.4 grams Dates, dries – 10 dates 4.2 grams

Pear, raw – 1 med, 4.1 grams

Fruit Lax Recipe

1 cup All Bran cereal ½ cup Prune Juice

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1 cup Applesauce

Mix all ingredients together in a bowl and leave for ½ hour so bran can soak up moisture. Mixture contains 2.4 grams in just under ¼ cup.

Number of Days Without Bowel Movement

Stool Softener: (Colace, Ducosate Sodium) Number of Tablets to be

Taken

Laxative: (Senokot or Glysennid) Number of Tablets to be Taken

Bowel Movement AM PM 1-2 1-2 0 0 Day One AM PM 1-2 1-2 1 1 Day Two AM PM 1-2 1-2 2 2 Day Three AM PM 1-2 1-2 3 3 Day Four* AM PM 1-2 1-2 4 4 Day Five AM PM 1-2 1-2 4 4

If following a well balance diet has not prevented this problem or if you are currently taking medications such as narcotics, that may cause constipation; the following routine may be useful:

• On day four without a bowel movement, call your doctor or community health professional for further instructions. (You may need to take a stronger laxative such as Lactulose or a suppository or fleet enema may be necessary.)

Reference: RNAO – Best Practice Guideline for Prevention of Constipation in the Older Adult – Synopsis BCCA – Suggestions for Dealing with Constipation

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Appendix: C

Bowel Assessment Sheet

Name: ____________________________________ Date Completed: _______________________ Admission Date: ___________________________

Level 1 Assessment:

1. Describe previous bowel patterns, if known (size, frequency, consistency, ease of expulsion) : • Size: < 1 cup ___ 1 – 1.5 cups ___ > 1.5 cups ___

• Frequency: daily ___ q 2 days ___ q 3 days ___ q 4 days ___ other___ • Consistency: hard formed ___ soft formed ___ loose unformed ___ fluid ___ • Ease of expulsion: no need to bear down ___ bears down effectively ___

Bears down with little effect or with pain ___

2. Describe current bowel patterns (size, frequency, consistency, ease of expulsion) : • Size: < 1 cup ___ 1 – 1.5 cups ___ > 1.5 cups ___

• Frequency: daily ___ q 2 days ___ q 3 days ___ q 4 days ___ other___ • Consistency: hard formed ___ soft formed ___ loose unformed ___ fluid ___ • Ease of expulsion: no need to bear down ___ bears down effectively ___

Bears down with little effect or with pain ___ 3. Results of rectal examination if done:

_____________________________________________________________________________________________ _____________________________________________________________________________

4. Previous use of oral laxatives:

• Type(s) ________________________________________________________________________ • Frequency ______________________________________________________________________ 5. Presence of:

• Excessive flatulence yes no

• Anorexia, yes no

• Fecal oozing / staining yes no

Level 2 Assessment:

1. Medical problems or surgeries affecting current bowel patterns:

• MS ___ Parkinson’s ___ Diabetes ___ CVA ___ Diverticulosis ___ Prolapse ___ • Anorectal / pelvic / abdominal surgery ___ Hemorrhoids ___ Hypothyroidism ____ • Other __________________________________________________________________ 2. Current intake of fluids & fiber in 24 hours:

• Fluids: < 800 ml ___ 800 - 1000ml ___ 1000 – 1200 ___ 1201 – 1500 ___ Other ___ • Fiber: Bran ________ Prunes ________ prune juice ________ fruit laxative __________ 3. Medications that contribute to constipation:

• Cogentin ___ tricyclic antidepressants ___ antihistamines ___ NSAIDS _____ • Anti parkinson drugs ___ antipsychotics/phenothiazines ___ Narcotic analgesics ___ • Dilantin ___ iron suppl’s ___ antihypertensives ____ Other ____________

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4. Results of abdominal examination:

_____________________________________________________________________________________________ _____________________________________________________________________________

5. Results of rectal examination:

_____________________________________________________________________________________________ _____________________________________________________________________________

6. Is aware of need to pass stool yes no

7. Can communicate need to pass stool yes no

8. Is able to sit safely on toilet / commode yes no

9. Is able to hold stool until they are put on the toilet yes no 10. Comments:

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________

Instruction for Use 1. Process for Use

a. The Bowel Assessment Sheet is completed by the RN or LPN on admission or as a result of a change in bowel status.

b. The completed form is placed in the same section as other focused assessments. c. All entries are completed in black ink.

d. A new form is completed each time there is a change in status. 2. Instruction for Use

a. The assessment can take place over a 2-3 week period if necessary. b. Complete Section 1 (Level 1 Assessment) for all residents on admission.

c. If the information in the first section indicates that the resident is constipated, complete Section 2 (Level 2 Assessment).

d. Include any information that is relevant to the assessment, but not included in the Bowel Assessment Tool in the “Comments” section.

e. If the resident has experienced a change in status that has affected bowel function, complete sections 1 and 2 of the tool.

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Appendix E

Clinical Practice Guideline: Impaction. Professional

Responsible:

Registered Nurse / Licensed Practice Nurse

Title: Guideline for the Care of a Resident / patient / Patient Who is Impacted

Indications: Indications of fecal impaction include a dilated rectum, abdominal distention and possibly pain, rectal discomfort and/or a feeling of fullness, painful defecation and a palpable fecal mass in the rectum. Impaction may also result in overflow incontinence of small amounts of liquid stool (bypassing), which occurs as a result of mucosal irritation above the fecal mass.

Symptoms characteristic of impaction in the elderly may also include sudden delirium, urinary frequency, incontinence or retention.

Care Outcomes: To prevent or appropriately treat constipation and thus avoid fecal impaction. If impaction occurs, the goal is to accurately assess and treat the impaction and, once resolved, to evaluate and revise the plan of care to prevent a recurrence. If untreated, fecal impaction high in the rectum or in the sigmoid colon can lead to bowel obstruction, resulting in a crisis situation for the resident / patient.

Definitions: Fecal impaction is defined as an accumulation of hard feces in the rectum or sigmoid colon that cannot be expelled by normal intestinal contractions or with the use of laxatives or enemas. RELATED STANDARDS:

1. Guideline for the Care of Resident / Patients with Constipation 2. Procedure for Disimpaction

SUPPORTIVE INFORMATION:

ASSESSMENT: Level 1 – Identification of the high risk resident / patient 1. Resident / patient who has had a previous impaction.

2. Resident / patient who has not had a BM for 5-6 days in response to oral and rectal laxatives ASSESSMENT: Level 2 – Assessment for Impaction

1. Assess abdomen for distention and rigidity. The resident / patient may indicate that they feel the need to defecate but cannot do so. If a mass is palpated in the lower left abdomen, it may be impacted stool in the sigmoid colon.

2. Assess for rectal pain and for areas of tenderness in the lower abdomen.

3. Perform digital rectal examination to assess for hard stool in the rectum, possibly accompanied by rectal distention. 4. Determine if the resident / patient is bypassing small amounts of stool and mucous around the fecal mass. The

bypassing stool is often the consistency of gravy and bypassing occurs frequently throughout the day. 5. Assess for recent onset of acute confusion or other significant change in behavior.

6. Assess for recent onset anorexia, with or without nausea and lethargy. 7. Assess for recent onset urinary frequency, retention or incontinence. INTERVENTIONS:

1. Call the GP and ask for an order for an anaesthetic gel / ointment such as Lidocaine before beginning disimpaction. 2. If hard stool is present, give an oil retention enema to soften the stool before any further intervention. Once the stool is

softened, a fleet can be given to assist the resident / patient to pass the fecal mass at the nurse’s discretion.

3. If the fleet is not successful or the mass is too large to pass, manual disimpaction is indicated. See the procedure for manual disimpaction. Note that excessive rectal manipulation may cause irritation of the mucosa, bleeding and stimulation of the vagus nerve, which can cause a reflex slowing of the heart rate. If these occur, disimpaction should be discontinued, the problems charted and the physician contacted. Disimpaction may be resumed the following day after discussion with the physician.

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4. Following removal of the fecal mass, give an oral laxative at HS to move any remaining stool into the rectum and an enema the following morning to ensure that the rectum is clearing.

5. If there is no stool in the rectum but stool is evident in the colon on examination of the abdomen, call the physician to discuss the need for an abdominal x-ray.

EVALUATION

1. Once the fecal mass and accumulated stool have been evacuated, it is imperative to evaluate previous bowel care and revise the interventions as necessary to avoid further episodes of impaction. It is appropriate to discuss alternate interventions with the GP and the Nutritionist. A LPN must discuss treatment options with an RN before changing the care plan.

DOCUMENTATION

1. Impaction is considered an unusual event, therefore the current problem of impaction and the interventions, including the resident’s / patient’s response to the interventions, is documented on the progress notes and communicated to the physician.

2. All residents / patients on a protocol for impaction must have a problem identifying the potential for future impaction documented on a care plan.

3. Once the impaction is resolved, appropriate assessment & interventions are documented on the care plan to avoid further problems with impaction.

References:

1. Jensen LL. Assessment and management of patients with bowel dysfunction and fecal incontinence. In D. Doughty (ed) Urinary and Fecal Incontinence: Nursing Management. (2nd Ed). Mosby; 2000: 353 – 383.

2. Prather, C & Ortiz-Camacho, C. Evaluation and treatment of constipation and fecal impaction in adults. Mayo Clin Proc. 1998; 72: 881-887.

3. Wrenn K. Fecal impaction. New England Journal of Medicine. 1989; 321: 658-662.

4. Alessi, C & Henderson, C. Constipation and fecal impaction in long term care patients. Clinics in Geriatric Medicine. 1988; 4:571-588

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Appendix: I

Bowel Care Audit Tool

Guidelines:

1. The sample (type & size) of resident’s / patient’s is chosen based on the purpose of the audit. 2. Complete the audit tool, for each resident / patient.

3. Following completion of the tool, compile the information.

4. Review and analyze the information & complete an audit summary.

Unit: ___________________________ Room Number: _____________________________________ Date: ______________________ Resident / patient Name/Number: ________________________________

Section 1

Instructions: Indicate “yes” or “no” by checking the appropriate box. Indicate the number of times an event happened in the blank space next to the line.

1. Additional fiber (bran/prunes/fruit lax) noted on bowel Record. yes ڤ no ڤ

2. Fiber information is consistent with Kitchen List yes ڤ no ڤ

3. Has a BM ≥ 2-7 times/week for ≤3 weeks out of 4 yes ڤ no ڤ

# ______

4. Has a BM _≥ 2-7 times/week for 4 weeks out of 4 yes _ڤ no _ڤ

5. Has had a hard stool at least once in the last month yes ڤ no ڤ # ______

6. Has had fecal oozing at least once in the last month yes ڤ no ڤ # ______

7. Has been disimpacted at least once in the last month yes _ڤ no _ڤ # ______

8. Has received a suppository 1 – 3 times a month yes ڤ no ڤ

# ______

9. Has received a suppository ≥ 4 times a month yes ڤ no ڤ

# ______

10. Has received an enema 1 – 3 times a month yes ڤ no ڤ

# ______

11. Has received an enema _≥ 4 times a month yes _ڤ no _ڤ

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Section 2

Instructions: Indicate whether the resident / patient get any of the following laxatives by checking “yes” or “no” in the appropriate box. When a resident / patient receives a laxative, note the dose and frequency in the appropriate space.

1. Glysennid tablets yes _ڤ no _ڤ; Dose _________ Frequency ____________________

2. Senokot granules yes ڤ no ڤ; Dose _________ Frequency ____________________

3. Milk of Magnesia yes ڤ no ڤ; Dose _________ Frequency ____________________

4. Lactulose yes ڤ no ڤ; Dose _________ Frequency

____________________

5. Colace yes _ڤ no _ڤ; Dose _________ Frequency

____________________ Section 3 Comments _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

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Appendix: A

Neurogenic Bladder Dysfunction and Management

Dysfunction Level of Damage Signs & Symptoms Management

Uninhibited Neurogenic Bladder

Cerebral Cortex Frequency

Urgency Urge Incontinence Obsessive Toileting Nocturia Bladder Capacity Habit toileting Anitcholinergic meds Bladder Training

Reflex Neurogenic Spinal Cord Damage Above Sacral Reflex Arc

Decreased Unpredictable / Involuntary Voiding Incomplete Voiding due to DSD No Urge to Void No Feeling of Fullness Reflex Triggering Techniques Intermittent Catheterization Autonomous (Areflexic) Neurogenic

Damage to the Sacral Reflex Arc Hypocontractile Detusor Muscle Decreased Bladder Capacity High Residuals Dribbling Incontinence with Overflow No Sensation of Fullness Strain (Valsalva) Manoeuvre Crede’s manoeuvre Intermittent Catheterization Sensory Paralytic Neurogenic Damage to Afferent (sensory) Nerve Fibres of the Sacral Reflex Arc

Sensations Intact

Absent Voluntary Control

Timed Voiding Intermittent Catheterization Motor Paralytic Neurogenic Damage to Efferent (Motor)

Nerve Fibres of the Sacral Reflex Arc

Sensation Intact

Absent Voluntary Control Incontinence Rare Intermittent Catheterization Strain (Valsalva) Manoeuvre Crede’s Manoeuvre

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Appendix: B

Management of Urinary Incontinence in Primary Care

Yes No No Yes No Yes No Yes Basic Evaluation

History, including assessment of risk factors, and bladder record

Physical examination

Measure post-void residual volume Urinalysis

Reversible Conditions Identified?

Incontinence Persistent. Patient Desires further evaluation

and Treatment Still Incontinent? Treat Reversible Conditions? Presumed Diagnosis Further Diagnostic Test Options Patient Cured Or Satisfied Initial Management Options Further Evaluation Required? Patient Cured Or Satisfied Treatment Key Yes – No Decisions Interventions