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CLINICAL PRACTICE GUIDELINES _NURSING_

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					                                     BallaratHealthServices

                       CLINICAL PRACTICE GUIDELINES
                                 (NURSING)

Number:                                                             EQuIP Number:



TO :                          All Staff

SUBJECT :                     Assessment of Bowel Elimination
Date Effective:
Reg. Authority:               Executive Director, Nursing Services
Date Revised:
Date for next review:
Review Responsibility:        Nursing Practice Committee
Scope:


DESIRED OUTCOME / OBJECTIVE:

1. There is timely identification of those at risk of developing bowel elimination problems.

2. Where a bowel problem exists, appropriate, thorough and prompt assessment is provided

3. The assessment is clearly documented

4. Management and treatment is appropriate and contemporary and based on a thorough
   assessment

POLICY
Individual bowel management programs are consistent with contemporary practice in the area,
implemented and reviewed at regular intervals.

Treatment and management of any bowel condition is based on a thorough individual assessment
and the rationale for treatment and management are clearly documented.

KEY CONCEPTS
Defining a normal bowel pattern
It is not necessary for people to open their bowels every day. While it is true that some people do
have daily bowel actions, most people don’t. It is considered normal for a person to open their
bowels anywhere from 3 times per day through to 3 times per week (Heaton et al, 1992). It is
more important for a person to have a regular, relaxed and easy bowel motion than it is for them
to go every day.
When defining normal bowel patterns, a number of factors need to be considered as well as
bowel motion frequency. A normal bowel motions should be:
• regular and within the normal frequency range (ie 3x/day to 3x/week)
• soft but formed, not hard or sloppy
• easy to pass without straining or pain
• followed by a feeling of having emptied the bowel properly

For definitions of constipation, diarrhoea, feacal incontinence see the associated BHS protocols.


ASSESSMENT
Routine screening of bowel patterns
On admission, all patients/residents will have their bowel elimination needs screened by the
bowel elimination questions on the nursing admission/assessment form relevant to the unit.

This screening should include:
• details of normal bowel habit
• when bowels were last opened
• currently used management (eg. any laxatives (prescribed and unprescribed) or special foods
   usually taken to promote regularity)
• presence of past/current bowel problems

Bowel pattern during the admission should then be recorded on the daily observation form or on
the daily bowel record if this is the routine practice in the unit.

Assessment of a specific bowel problem
If there are concerns about a person’s bowel status or a problem is identified a more thorough
assessment is required.

A specific assessment of bowel function should be initiated if:
1. a person is thought to be at significant risk of developing a bowel problem
2. a bowel problem has been reported or noted
3. when the person’s bowel status deteriorates or changes suspiciously
4. a person on a bowel management/prevention plan needs periodic review (ie. in residential
   care)
The assessment should be commenced as soon as possible following the identification of the
problem and completed within 7 – 14 days.

A Bowel Elimination Assessment will include:
1. The BHS Bowel Elimination Assessment form (MR/209.2) which assists in collecting all the
   data required for a nursing bowel assessment including:
   •       a history of bowel elimination pattern – including continence status
   •       a history of relevant general conditions that may impact on bowel status
   •       a review of medications that may impact on bowel status
   •       an review of nutritional status in relation to bowel elimination
2. The BHS Bowel Elimination Observation Chart (MR/550.0) which includes observations of:
• frequency and timing of bowel motions
• consistency (or form) of stools (using the Bristol Stool Form Scale – Heaton et al, 1994)
• amount or size of stools
• presence of straining, pain etc associated with a bowel motion
• presence of abnormalities in the stool such as blood, mucous, fat or undigested food
3. A physical examination may be conducted and appropriately documented by an RN Div 1 or
   medical staff which may include:
   •      examination of the abdomen (palpation and auscultation) for as signs such as
      abdominal tenderness, a mass and decreased bowel sounds
   •      perineal inspection, looking for abnormalities such as evidence of soiling, rectal
      prolapse, peri-anal scaring, a gaping anus or perineal descent or haemorrhoids
   •      a rectal examination to determine amount and type of faeces in the rectum, the
      presence of any rectal mass and the state of anal sphincter tone

Length of time for bowel observation & charting
The best amount of time for assessment bowel charting has not yet been established by research.
However, the length of stay and the type of unit to which the person is admitted will clearly
influence the amount of charting that is possible. The purpose of the observation also will
influence the time it is maintained.
1. for initial observation
• Acute Care ∧ observe and chart for 3 days up to one week or as required by medical staff
• Sub-acute or Residential Care ∧ it is preferable to observe and chart for assessment of a
    bowel problem for a week or as directed by medical or specialist nursing staff.
2. for monitoring
• during implementation of the treatment and management strategies maintain the bowel
    observation chart to observe the effectiveness of these strategies
• once the goals of treatment/management have been reached (ie the management is working),
    recording the frequency of bowel actions on daily observation charts or on a daily bowel
    sheet as per the unit’s policy is adequate

Suggestions to help with assessment:
1. Involve the patient or resident in their own bowel charting if possible and appropriate eg. by
   giving them an illustrated stool form chart so they can observe their own bowel motions
2. Maintain a detailed chart only as long as required
3. In residential care units, limit the number of people being assessed to one or two per unit at a
   time to minimize staff workload and reduce the risk of confusion

TREATMENT AND MANAGEMENT
A decision regarding the type of bowel elimination problem is made following thorough
assessment. An individual management plan is based on this assessment in consultation with
medical staff and with the person as appropriate. The plan of care is documented as per the unit’s
protocol.

   See BHS management protocols/guidelines for the specific bowel elimination problems of
             constipation (no. #), diarrhoea (no. #), faecal incontinence (no. #).

EVALUATION
The management program is to be evaluated to determine if the nursing interventions are
achieving the goals of care.

For a routine evaluation such as required in residential care (12 monthly), a Bowel Elimination
Observation Chart (MR/550.0) is to be completed for at least 3 days and preferably a week while
the management plan is in place. If the person’s bowel pattern is demonstrated to be satisfactory
and continues to meet the care plan goals, no further assessment is required. However, the Bowel
Elimination Assessment form (MR/209.2) will need to be repeated if the evaluation bowel chart
demonstrates a problem, or if a problem is identified by either the person or the staff between
routine evaluation.

REFERENCES:
Heaton, K.M., Radvan, J., Cripps, H., Mountford, R.A., Braddon, F.E.M., Hughes, A.O., 1992, “
Defecation frequency and timing, and stool form in the general population: a prospective study”,
Gut, 33, 818-824

Heaton, K.M., O'Donnell, L.J.D. 1994, “An Office Guide to Whole-Gut Transit Time: Patient's
Recollection of their Stool Form”, Journal of Clinical Gastroenterology, 19(1), 28-30

				
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