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Digital Rectal Examination and Manual Removal of Faeces Clinical

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Digital Rectal Examination and Manual Removal of Faeces Clinical Powered By Docstoc
					     Clinical Guidelines for Digital Rectal
 Examination, Manual Removal of Faeces and
 Insertion of Suppositories /Enemas for Adult
                  Care only
                  Clinical Policy file ref no: 6


APPROVED BY:                                    DATE
Policy and Guideline Ratification Group         30.4.10
Integrated Governance Committee                 N/A




                                      Implementation Date: July 2010
                                                        Version: 2.2
                                             Review Date: April 2012
                   Author: Roslyn Davies, Continence Nurse Assessor
                                        Continence Advisory Service
NHS South Gloucestershire


Document status: Current


Version     Date                    Comments


1.0         July 2006               Guideline implemented


2.0         February 2009           Guideline sent to PGRG for review and approved
                                    subject to minor changes


2.1         April 2009              Guideline sent back to Governance Team following
                                    minor amendments by Bristol and West Continence
                                    Partnership


2.2         April 2010              Document approved by Policy and Guidelines
                                    Ratification Group with minor amendments. To be
                                    distributed via the clinical policy file list.




If you need further copies of this document please contact Continence Advisory
Service.

South Gloucestershire has made every effort to ensure this policy does not have the
effect of discriminating, directly or indirectly, against employees, Service Users,
contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national)
origin, sex, sexual orientation, marital status, religious belief or disability. This policy
will apply equally to full and part time employees. All NHS South Gloucestershire
policies can be provided in large print or Braille formats if requested, and language
line interpreter services are available to individuals of different nationalities who
require them.



                                                                                          1
Contents

1.      Introduction                                                       Page 3
2.      Scope                                                              Page 3
3.      Consent                                                            Page 3
4.      Assessment                                                         Page 4
5.      Manual Evacuation of Faeces                                        Page 4
        5.1     Observation prior to procedure                             Page 4
6.      Indications for Digital Rectal Examination                         Page 5
        6.1     Special precautions                                        Page 5
7.      Indications for the use of suppositories/enemas                    Page 5
        7.1     Special precautions                                        Page 5
8.      Manual evacuation as an acute intervention                         Page 5
        8.1     Manual evacuation as a regular intervention                Page 6
        8.2     Circumstances when extra care is required                  Page 6
        8.3     Exclusions and contraindications                           Page 6
9.      Health promotion/service user education                            Page 6
10.     The Bristol stool form scale                                       Page 7
11.     Procedure for Digital Rectal Examination/Manual evacuation of      Page 8
        faeces
        11.1 Procedure                                                     Page 8
12.     Procedure for insertion of suppositories or enema                  Page 9
        12.1 Procedure                                                     Page 9
13.     Digital stimulation                                                Page 10
        13.1 Procedure for Digital Stimulation                             Page 10
        13.2 Procedure                                                     Page 10
14.     Equality impact assessment                                         Page 11
15.     Review of these guidelines                                         Page 11
16.     References and further reading                                     Page 11

Appendix 1     Clinical audit data collection tool                         Page 13
Appendix 2     Standard                                                    Page 14


The failure to comply/adhere to these guidelines may be investigated in line with the
‘Investigating (Employment) complaints and allegations policy and procedure’ and may result
in disciplinary action, up to and including dismissal.




                                                                                         2
THESE GUIDELINES RELATE TO ADULT CARE ONLY.

1.      Introduction

Digital Rectal Examination (D.R.E) and manual evacuation of faeces are invasive procedures
and should only be performed when necessary and after individual assessment and consent has
been obtained.

Manual evacuation should be avoided if at all possible since it is a distressing, often painful and
potentially dangerous procedure for the service user.

Cultural, religious beliefs and the dignity and privacy of the service user must be a priority and
considered before performing these procedures

Where this document refers to ‘the PCT’, it shall be understood to mean NHS South
Gloucestershire.

When referring to users of health services in the PCT, e.g. service users, clients, patients etc, the
term ‘service user’ will be used.


2.      Scope

These procedures must only be carried out by Health Professionals who have received suitable
training and been assessed as competent to carry out the procedure. It should only be
performed when all other methods of relieving constipation have failed and the service
user has been informed of treatment options and the risks involved.

This procedure is not to be used as a means of examining the prostate gland in male
service users.

Healthcare Professionals must use their professional judgement concerning appropriate use of
these procedures. If this differs from that of the service user or carer, consultation with colleagues
especially the service users GP is advised.

These guidelines should be read in conjunction with the following PCT policies:

•    Policy for the administration, handling and recording of medications (all routes)
•    Prevention and Control of Infection Policies
•    Consent Policy
•    Policy statement for the use of the Royal Marsden Manual of Clinical Nursing procedures
     online, current edition
•    Mental Capacity Act 2005 Practice Guidance
•    Privacy and Dignity policy
•    Waste Management policy
•    Safeguarding Adults and Cause for Concern Guidance
•    Chaperoning Guidelines for Intimate Examination Procedure and Care


3.      Consent

Valid, informed consent must be obtained from service user and carer (where relevant) and
documented prior to undertaking DRE or manual evacuation of the rectum. The Mental Capacity
Act 2005 provides a statutory framework to empower and protect vulnerable adults aged 16 and
over who are not able to make their own decisions.


                                                                                               3
4.      Assessment

DRE may be used as part of a complete full bowel assessment to establish the presence of a
stool in the rectum. However, it must not be used as a primary investigation in the assessment
and treatment of constipation.

DRE may be used to establish the following:

•    Presence and nature of faecal matter in the rectum.
•    Anal tone and ability to initiate a voluntary sphincter contraction and to what degree.
•    Anal / rectal sensation.
•    Need for or effects of rectal medication in some circumstances.
•    Need for manual removal of faeces and evaluating bowel emptiness.
•    Outcome of rectal / colonic washout / irrigation if appropriate.
•    The need and outcome of using digital stimulation to trigger defecation by stimulating the
     recto-anal reflex.

NB it is vital to check for allergies (including latex, soap (lanolin), phosphate and peanut
before conducting these procedures).


5.      Manual evacuation of faeces

This may be undertaken for:

•    Faecal impaction / loading.
•    Incomplete defecation.
•    Inability to defecate.
•    When other bowel emptying techniques have failed.
•    Neurogenic bowel dysfunction in Service users with Spinal Injury.

5.1 Observation prior to procedure

Before undertaking DRE or Manual evacuation of faeces, abnormalities of the perineal and peri-
anal area should be observed, looking for:

•    Rectal prolapse – (degree, ulceration).
•    Haemorrhoids – (their number, position, grade, prolapsed).
•    Anal skin tags – number, position, condition.
•    Wounds, dressings, discharge.
•    Anal lesions (malignancy).
•    Gaping anus.
•    Skin conditions, broken areas, pressure sores of all grades.
•    Bleeding and the colour of the blood.
•    Faecal matter/ stool consistency.
•    Infestation.
•    Foreign bodies.

Any of the above should be documented and reported to service users GP as appropriate.

Following the procedure(s) stool consistency, volume and observations of bleeding, discharge
should be documented.


                                                                                              4
6.       Indications for digital rectal examination:

•     To assess anal sphincter tone and sensation.
•     To assess if faecal matter is present and if so the amount and consistency.
•     To undertake digital stimulation in service users with obstructive constipation to trigger
      defecation.
•     To assess the need for rectal medication and/or to evaluate its outcome in service users
      who are unable to communicate or who have diminished anal/rectal sensation.

6.1      Special precautions:

•     Active inflammation of the bowel.
•     Recent radiotherapy to the pelvic area.
•     Rectal/ anal pain.
•     Rectal surgery or trauma to the anal/ rectal area.
•     Service users with tissue fragility.
•     Obvious rectal bleeding.
•     Service users with a history of sexual abuse or any other forms of abuse.
•     Autonomic dysreflexia.


7.       Indications for the use of suppositories/enemas

•     To empty the rectum prior to investigations and surgical operation.
•     As a treatment for constipation.
•     As a route for the administration of medicines.
•     As a treatment for haemorrhoids or anal purities.

7.1      Special precautions:

•     Recent colorectal surgery.
•     Malignancy (or other pathology) of the perianal region.
•     Low platelet count.
•     Rectal bleeding.


8.       Manual evacuation as an acute intervention

When undertaking this procedure as an acute intervention, the following observations and risk
factors should be considered and documented:

•     Pulse at rest prior to the procedure to obtain a baseline, as vagal stimulation can slow the
      heart rate.
•     Pulse during the procedure.
•     Blood pressure in spinal injury service users prior to, during and at the end of the procedure
      (observe for potential signs of autonomic dysreflexia).
•     Signs & symptoms of autonomic dysreflexia: i.e. headache, flushing, sweating, hypertension,
      service user should be encouraged to inform the nurse when experiencing any sign or
      symptom.
•     Distress, pain, discomfort.
•     Bleeding.
•     Collapse (of service user).
•     Allergies to latex, soap (lanolin), phosphate and peanuts.



                                                                                               5
The procedure should be discontinued / not commenced if the presence or risk of such factors is
present, and medical advice should then be sought.

8.1      Manual evacuation as a regular intervention

Observation / risk factors to consider include:

•     Distress, pain, discomfort.
•     Bleeding.
•     Signs and symptoms of autonomic dysreflexia – as in 6 above.
•     Collapse (of service user).
•     Stool consistency.

8.2      Circumstances when extra care is required

•     Active inflammation of the bowel e.g. Crohns’s disease, Ulcerative Colitis, Diverticulitis.
•     Recent radiotherapy to pelvic area.
•     Rectal / anal pain.
•     Tissue fragility.
•     Service user taking anti-clotting medication.
•     Obvious rectal bleeding.
•     Known history of sexual abuse.
•     In spinal injury service users (spinal injury T6 or above) due to autonomic dysreflexia.
•     Known history of allergies (see 3 above).

8.3      Exclusions and contra-indication

Health Care Professionals must not perform these procedures when:

•     The service user does not consent.
•     For adults who lack capacity to give consent, please refer to the Mental Capacity Act 2005.
•     The service user’s doctor has specifically instructed this procedure should not be undertaken.
•     Recent rectal / anal surgery or trauma.
•     The Healthcare Professional does not feel they have competence in this procedure.


9.       Health promotion/ service user education

The service user / carer will be provided with contact numbers for the Community Healthcare
Professional team.




                                                                                                    6
10.




      7
11.      Procedure for Digital Rectal Examination / Manual Evacuation of Faeces

Equipment required
Protection for the bed
Latex free gloves (non sterile)
Disposable plastic apron
Tissues
Lubricating gel or Lignocaine gel
Bag for disposal of used items

11.1     Procedure:

•     Collect and prepare equipment.
•     Explain procedure to service user to obtain service user consent/co-operation.
•     Ensure privacy and dignity and reassure service user at each stage.
•     Take service users pulse rate at rest prior to and during the procedure.
•     Take pulse and blood pressure in spinal injured service users prior to, during and at the end
      of the procedure.
•     Prepare the service user, assist with removing clothing from waist down, help in
      positioning service user on left lateral position, knees flexed, taking into consideration the
      normal line of the sigmoid colon.
•     Ensure that the service user is warm.
•     Protect bedding and mattress.
•     Wash hands with soap and water or alcohol hand rub, put on disposable gloves.
•     Observe the anal area (See section 5 for DRE).
•     Lubricate the gloved index finger; inform the service user that you are about to perform
      the procedure.
•     Ask the service user to relax prior to insertion of index or middle finger.
•     Insert the gloved finger into the anus slowly and on into the rectum reducing trauma to
      mucosal lining/assess anal sphincter control resistance should be felt.
•     Assess for faecal matter, document the amount and consistency, using the Bristol stool
      scale form (see section 10).
•     For manual removal of faeces, bring down faeces for removal with lubricated finger.
•     The first manual evacuation, to minimise discomfort lignocaine gel may be required and
      waiting time allowed for it to take effect.
•     In Scybala-type stool (a very large mass of solid stool in the rectum) remove the stool a
      lump at a time.
•     In a mass, push finger into middle of faecal mass and divide it then remove small
      amounts of faeces in sections.
•     Retain faeces in gloved hand or discard into suitable receptacle (renew glove as
      necessary).
•     Assess need for medication (or outcome of medication, for example following treatment
      of constipation).
•     Clean anal area; remove gel by wiping residual from area to ensure that it does not
      cause irritation or soreness.
•     Dispose of equipment as per PCT Waste Management Policy.
•     Record Post DRE observations of pulse and BP if required at the end of the procedure.
•     Help service user to get up and dressed and into a comfortable position, offer toileting
      facilities as appropriate.
•     Provide written information if indicated.
•     Document procedure fully on completion in the service user’s records.




                                                                                                8
12.      Procedure for Insertion of suppositories or enema

Equipment required                              Notes
Protection for the bed
Latex free gloves (non sterile)
Disposable plastic apron
Tissues
Lubricating gel or Lignocaine gel
Bag for disposal of used items
Suppositories/enema as prescribed               Prescribed by GP or Nurse prescriber
Bowl of warm water                              To warm enema to body temperature
Bath Thermometer                                A temperature of 40.5 C-43.3 C is
                                                recommended for adults. Oil retention
                                                enemas should be warmed to 37.8 C

12.1     Procedure:

•     Collect and prepare equipment (including warming enema to body temperature).
      Warming the enema solution may be beneficial as heat stimulates the rectal mucosa;
      cold solutions should also be avoided as this may cause cramping. (Dougherty and
      Lister 2004).
•     Explain procedure to service user to obtain consent/co-operation.
•     Ensure privacy and dignity.
•     Ensure service user is warm.
•     Allow service user to empty bladder first if necessary.
•     Take service users pulse rate at rest prior to and during the procedure.
•     Take pulse and blood pressure in spinal injured service users prior to, during and at the
      end of the procedure.
•     Prepare the service user; assist with removing clothing from waist down, help in
      positioning service user on left lateral position, knees flexed, taking into consideration the
      normal line of the sigmoid colon.
•     Protect bedding and mattress.
•     Wash hands with soap and water or alcohol hand rub, put on disposable gloves.
•     Observe the anal area (see section 5 for DRE)
•     Lubricate the gloved index finger; inform the service user that you are about to perform
      the procedure.
•     Ask the service user to relax prior to insertion of index or middle finger.
•     Insert the gloved finger into the anus slowly and on into the rectum.
•     Assess for faecal matter, document the amount and consistency, using the Bristol stool
      scale (see section 10).
•     Assess need for medication.
•     Lubricate the blunt end of the suppository or the tube tip of enema (after cap has been
      removed); inform the service user that you are about to perform the procedure, then
      insert the suppository/enema via the anus into the rectum.
•     If retention enema is used introduce the fluid slowly and then if possible, elevate the foot
      of the bed to 45 degrees.
•     If evacuation enema is used again introduce fluid slowly, roll the enema from the bottom
      to prevent back flow.
•     Clean anal area; remove gel by wiping residual from area to ensure that it does not
      cause irritation or soreness.
•     If evacuation enema is used ask service user to retain enema for 10-15 minutes prior to
      bowel evacuation.
•     Dispose of equipment as per waste management policy.



                                                                                                  9
•     Help service user to get up and dressed and into a comfortable position, offer toileting
      facilities as appropriate.
•     Provide written information if indicated.
•     Document procedure fully in service user’s records.


13.      Digital Stimulation

Definition: Where a gloved finger is placed into the rectum and slowly rotated, whilst
maintaining contact with the rectal wall, to stimulate reflex bowel activity (Slater 2004).

Indications: Service users with Tetraplegia and paraplegia who have an upper motor
neurone cord lesion (T12 and above) generally have reflex bowel activity (Stowell et al
2002).

This reflex can be triggered to act by the use of suppositories or by digital stimulation or both
(Zejdlik 1992).

Ingestion and passage of liquid or semi-solid material from the stomach stimulates natural
waves of peristalsis in a descending pattern towards the sigmoid colon (gastro-colic
reflex).This reflex is generally strongest following the first meal of the day and therefore,
bowel care for these service users is best carried out after a meal or hot drink (Zejdlik 1992;
Powell and Rigby 2000). Additional stimulation at this time can be provided through
abdominal massage, which can cause relaxation of the sigmoid sphincter (Frankel1967).

Better results can be achieved if the service user is able to sit over a toilet, due to
gravitational influences (Stowell et al 2002; Powell and Rigby 2000). This would necessitate
hoisting service users with a high lesion into a shower chair, which is then placed over the
toilet. Some service users do not have sufficient balance to sit on a shower chair and will
need to have bowel care carried out whist they lie in bed in the left lateral position (Stowell et
al 2002).

13.1     Procedure for Digital Stimulation

(Usually preceded by the insertion of suppositories)

Equipment required
Protection for the bed
Latex free gloves (non sterile)
Disposable plastic apron
Tissues
Lubricating gel or Lignocaine gel
Bag for disposal of used items

13.2     Procedure

•     Collect and prepare equipment.
•     Explain procedure, obtain service users consent/co-operation.
•     Maintain service user’s privacy and dignity.
•     This procedure can be carried out with the service user seated on a toilet/commode or
      shower chair, an upright position is essential to allow evacuation to be assisted by
      gravity. If service users balance is suited to this. If not the service user should be
      positioned in the left lateral position or in a left sided pelvic twist, to expose the anus.
•     Ensure any protective equipment is used to protect the bed.



                                                                                                 10
•     Wash hands and put on apron and gloves (double gloving may be appropriate) to give
      hands protection and minimise cross infection.
•     Inform service user when you are ready to commence procedure (to enable them to
      relax).
•     Observe the anal area (see section 5 for DRE)
•     Lubricate the gloved index finger; inform the service user that you are about to perform
      the procedure.
•     Gently insert one finger 2-4 cm into the rectum (to avoid trauma to the anal mucosa and
      prevent forced over dilation of the anal sphincter).
•     Gently rotate the finger in a circular motion, maintaining contact with the rectal wall, until
      the internal sphincter relaxes (this will trigger reflex and promote emptying of the
      rectum).
•     Do not stimulate for more than one minute (to prevent damage to anal canal).
•     Stop if service user experiences distress ie. If severe spasms of the anal sphincter occur
      or signs of autonomic dysreflexia.
•     Move the finger to one side while faeces pass out of the anal canal
•     This is repeated until the stool has been passed and the rectum is empty (repeat
      stimulation every 3-5 minutes until reflex activity stops)
•     Following defecation check the rectum for faeces, if bowel is not empty the service user
      may require a manual evacuation of faeces.
•     If no reflex activity occurs do not repeat digital simulation more than 3 times. Proceed to
      manual evacuation if faeces are present. This is to prevent damage to the anal sphincter,
      ensure complete evacuation and prevent faecal incontinence.
•     When finished slowly remove finger from service users rectum (if rectal medication is to
      be administered it should be done at this point) thus minimising service user discomfort.
•     Remove top glove and clean service user’s perianal area with soap and water or
      proprietary foam leaving service user comfortable and reducing the risk of cross
      infection.
•     Record Post DRE observations of pulse and BP if required.
•     Ensure anal area is clean and dry observe anal area after completion of procedure, thus
      preventing infection /contamination and noting if there is any evidence of trauma to
      surrounding skin.
•     Remove gloves and dispose of waste in appropriate waste disposal bag. Wash hands, to
      minimise cross infection.
•     Ensure service user is comfortable and that there are no signs of ill effects.
•     Record procedure in records.


14.      Equality Impact Assessment

These clinical guidelines have been assessed as having no impact on any minority groups.


15.      Review of these guidelines

The clinical audit data collection tool (appendix 1) and evaluation of standard (appendix 2)
will be completed annually by the Healthcare teams


16.      Bibliography and further reading.

Addison R (1999) Practical procedures for nurses No 33.1 Digital rectal examination1. Nursing
Times, 95(40): insert 2p.




                                                                                                 11
Addison R (1999) Practical procedures for nurses No 33.2. Digital rectal examination2. Nursing
Times, 95(41): insert 2p.

Higgins Dan (2006) How to administer an enema. Nursing Times. Vol 102 No20 p24, 25.

Lister.S & Dougherty L (2008). The Royal Marsden Hospital. Manual of Clinical Nursing
Procedures.

Moppett S (1999) Practical procedures for nurses No 28.1 Administration of an enema. Nursing
Times, 95(22: insert 2p.

Moppett S & Parker M (1999) practical procedures for nurses No 29.1. Insertion of a suppository.
Nursing Times, 95(23): insert 2p

Ness W (2008) Faecal Incontinence. What influences care and management options. BMJ Vol 17
no 18

Norgine Pharmaceuticals (2008). The Procedure for the Digital Removal of Faeces Guidelines. A
publication endorsed by the Association for Continence Advise (ACA), Royal College of Nursing
(RCN) and the Spinal Injury Association (sia)

NICE (2007) Faecal Incontinence Guideline 49 June 2007
www.nice.org.uk

RCN (2008) Bowel Care Including Digital Examination of the rectum & manual evacuation of
faeces - The Role of the Nurse. (March 2008)


Slater Wendy (2004) Bowel care for service users with a spinal cord lesion Salisbury NHS
Trust

South Glos PCT (2009) DRE Portfolio




                                                                                           12
Appendix 1
                                            Standard


                         CLINICAL AUDIT DATA COLLECTION TOOL


Objective. To audit the standard of Digital Rectal Examination by community Healthcare
Professionals.

Methodology. Manual search of records held on client documentation and discussion with
Healthcare practitioner.


Sample size. A random sample of 3 clients per team will be identified by auditor. An audit of
these records will take place.




Please tick YES or NO

                                                                        YES     NO


1. Is there documented evidence that the procedure has
   been carried out in accordance with Trust Policy?


2. (Ask Healthcare Professional) to identify process
   for disposing of waste matter following DRE


3. (Ask Healthcare Professional) Have you received
   training in accordance with Trust Policy?




`




                                                                                           13
                                                STANDARD                                       Appendix 2

Topic: Community Healthcare Professionals                                           Implementation Date: March 2009

Sub Topic: Digital Rectal Examination & removal of Faeces                           Review Date:

Care Group: Service users on a Community Caseload                                   Signature…………………. (Clinical Lead Adult Services)
Objective: All community Healthcare staff carrying out Digital Rectal Examination & Manual Removal of Faeces will do so safely in
accordance with Trust guidelines.
Standard Statements                                                                                Target        Exceptions
   1. All Healthcare Professionals performing Digital Rectal Examination & Manual Removal          100%          Nil
    of Faeces are deemed competent and have been trained appropriately according to
    Trust guidelines.
    2. Explanation has been given to the service user/carer and valid, informed consent for the    100%          Where service user is unable
    Procedure has been obtained and documented.                                                                  to consent in accordance
                                                                                                                 with PCT Consent Policy
    3. The procedure will be carried out in accordance with Trust guidelines                       100%          Nil
    4. The Service user/carer will be provided with contact telephone numbers for the Healthcare 100%            Nil
        Team.
    5. The procedure will be documented.                                                           100%          Nil
    6. Service user/carer education will be documented.                                            100%          Nil
Instructions for data collection 1, 3 via peer review and questioning of practice 2, 4 – 6 via manual search of records.

Source of Evidence

       RCN Bowel Care including manual removal of faeces. Guidance for nurses. March 2008
       Reference to Guidelines for the management of bowel care Salisbury Health Care NHS Trust.
       The Royal Marsden Hospital of Clinical Nursing Procedures 2008
       NICE Faecal Incontinence Clinical Guideline 49. June 2007




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