Assessment of Impairment and Disability
- A systematic, comprehensive evaluation of bowel function, impairment, and possible problems should be completed at the onset of SCI and at least annually throughout the continuum of care.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- The patient history should include the following elements
:
- Premorbid gastrointestinal function and medical conditions.
- Current bowel program, including patient satisfaction.
- Current symptoms, including abdominal distention, respiratory compromise, early satiety, nausea, evacuation difficulty, unplanned evacuations, rectal bleeding, diarrhea, constipation, and pain.
- Defecation or bowel care (assisted defecation procedure) frequency, and duration and characteristics of stool.
- Medication use and potential effect on bowel program.
(Scientific evidence-three level V studies for assessment of symptoms, otherwise none; grade of recommendation-C/expert consensus; strength of panel opinion-strong).
- A physical examination should be done at the onset of SCI and annually thereafter. The examination should include
:
- Complete abdominal assessment, including palpation along the course of the colon.
- Rectal examination.
- Assessment of anal sphincter tone.
- Elicitation of anocutaneous and bulbocavernosus reflexes to determine if the patient has UMN or LMN bowel.
- Stool testing for occult blood beginning at age 50.
(Scientific evidence-none, clinical practice guidelines for colorectal cancer screening; grade of recommendation-C/expert consensus; strength of panel opinion-strong[onset], moderate [annual]).
Assessment of Function (Disability)
- An assessment of knowledge, cognition, function, and
performance should be conducted to determine the ability of the individual
to complete bowel care or to direct a caregiver to complete the procedure
safely and effectively. The assessment should include the following
elements
:
- Ability to learn.
- Ability to direct others.
- Sitting tolerance and angle.
- Sitting balance.
- Upper extremity strength and proprioception.
- Hand and arm function.
- Spasticity.
- Transfer skills.
- Actual and potential risks to skin.
- Anthropometric characteristics.
- Home accessibility and equipment needs.
(Scientific evidence-V; grade of recommendation-C; Strength of panel opinion-strong).
Designing A Bowel Program
- The bowel program should provide predictable and effective elimination and reduce evacuation problems and gastrointestinal complaints. Bowel programs should be revised as needed throughout the continuum of care.
(Scientific evidence-two level V studies, one review article, and one clinical textbook; grade of recommendation C/expert consensus; strength of panel opinion-strong).
- Within established parameters of safety and effectiveness, the design of the bowel program should take into account attendant care, personal goals, life schedules, role obligations of the individual, and self-rated quality of life.
(Scientific evidence-V; grade of recommendation-C; strength of panel opinion-strong).
- Bowel programs should be initiated during acute care and continued throughout life, unless full recovery of bowel function returns. Differences in bowel programs for reflexic and areflexic bowels include type of rectal stimulant, consistency of stool, and frequency of bowel care. To establish a bowel program
:
- Encourage appropriate fluids, diet, and activity.
- Choose an appropriate rectal stimulant.
- Provide rectal stimulation initially to trigger defecation daily.
- Select optimal scheduling and positioning.
- Select appropriate assistive techniques.
- Evaluate medications that promote or inhibit bowel function.
(Scientific evidence-none, clinical textbooks and nursing procedure manuals; grade of recommendation-expert consensus; strength of panel opinion-strong).
- A consistent schedule for defecation should be established based on factors that influence elimination, preinjury patterns of elimination, and anticipated life demands.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- Mechanical and/or chemical rectal stimulation should be prescribed to predictably and effectively evacuate stool.
(Mechanical: Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong. Chemical: Scientific evidence-two level III studies and one level V study; grade of recommendation-C; strength of panel opinion-strong).
- The use of assistive techniques should be
individualized and their effectiveness in aiding evacuation should be
evaluated. Push-ups, abdominal massage, Valsalva maneuver, deep breathing, ingestion of warm fluids, and a seated or forward-leaning position are some of the techniques used to aid in bowel emptying.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-moderate).
Nutrition
- Individuals with SCI should not be placed uniformly on high fiber diets. A diet history should be taken to determine the individual's usual fiber intake. The effects of current fiber intake on consistency of stool and frequency of evacuation should be evaluated. A diet containing no less than 15 grams of fiber daily is needed initially. Increases in fiber intake should be done gradually, from a wide variety of sources. Symptoms of intolerance should be monitored, and reductions in fiber are recommended, if they occur.
(Scientific evidence-V; grade of recommendation-C; strength of panel opinion-strong).
- The amount of fluid needed to promote optimal stool consistency must be balanced with the amount needed for bladder management. In general, fluid intake should be
approximately 500 ml/day greater than the standard guidelines used to
estimate the needs of the general public (National Research Council, 1989).
Standard guidelines indicate that adult fluid needs can be estimated by
either of the following formulas
:
1 ml fluid/Kcal of energy needs + 500 ml/day
OR
40 ml/kg body weight + 500 ml/day
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-moderate).
Managing The Neurogenic Bowel At Home Or In The Community
- Appropriate adaptive equipment for bowel care should be prescribed based on the individual's functional status and discharge environment.
(Scientific evidence-one level V study for bowel care/shower chair, otherwise none; grade of recommendation-C/expert consensus; strength of panel opinion-strong).
- Careful measures should be taken to avoid pressure ulcers and falls related to the use of bowel care equipment.
(Scientific evidence-one level V study; grade of recommendation-C/expert consensus; strength of panel opinion-strong).
- Adequate social and emotional support should be available to help individuals manage actual or potential disabilities and handicaps associated with neurogenic bowel.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- All aspects of the bowel management program should be designed to be easily replicated in the individual's home and community setting.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
Monitoring Program Effectiveness
- The following variables should be monitored during and documented after every bowel care procedure during hospitalization or when developing or revising a bowel program in any community setting
:
- Date and time of day.
- Time from rectal stimulation until defecation is completed.
- Total time for completion of bowel care.
- Mechanical stimulation techniques.
- Pharmacological stimulation.
- Position.
- Color, consistency, and amount of stool.
- Adverse reactions.
- Unplanned evacuations.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- When a bowel program is not effective (i.e., if
constipation, GI symptoms or complications, or unplanned or delayed
evacuations occur) and a consistent schedule has been adhered to, changes in
the following components should be considered
:
- Diet.
- Fluid intake.
- Level of activity.
- Frequency of bowel care.
- Position/assistive techniques.
- Type of rectal stimulant.
- Oral medications.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- In the absence of adverse reactions and indicators for potential medical complications, the bowel care regimen should be maintained for 3 to 5 bowel care cycles prior to considering possible modifications. Only one element should be changed at a time.
Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- When evaluating individuals complaining of bowel management difficulties, adherence to treatment recommendations should be assessed.
Scientific evidence-V; grade of recommendation-C; strength of panel opinion-strong).
- Colorectal cancer must be ruled out in individuals with SCI over the age of 50 with a positive fecal occult blood test or with a change in bowel function that does not respond to corrective interventions.
(Scientific evidence-clinical practice guideline; grade of recommendation-none given; strength of panel opinion-strong).
Managing Complications of the Neurogenic Bowel
- Knowledge of the unique clinical presentation and prompt diagnosis of common complications are necessary for the effective treatment of conditions associated with the neurogenic bowel in individuals with spinal cord injury.
Scientific evidence-V; grade of recommendation-C; strength of panel opinion-strong).
- Constipation after SCI is manifested by unusually
long bowel care periods, small amounts of results, and dry, hard stools. Its causes should be investigated.
(Scientific evidence-none; grade of recommendations-expert consensus; strength of panel opinion-strong).
- Management of chronic constipation in individuals
with SCI should start with the establishment of a balanced diet, adequate
fluid and fiber intake, increased daily activity, and to the extent possible,
reduction or elimination of medication contributing to constipation. If evacuation of stool has not occurred within 24 hours of scheduled evacuation or if stool is hard-formed and difficult to pass, a trial is warranted of a bulk-forming agent or of one or more of the following categories of laxative agents: lubricants, osmotics, and stimulant cathartics. These agents should be ingested at least 8 hours before planned bowel care.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- Effective treatment of common complications of neurogenic bowel in individuals with spinal cord injury, including fecal impaction and hemorrhoids, is necessary to minimize potential long-term morbidities.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- Prokinetic medication should be reserved for use in individuals with severe constipation or difficulty with evacuation that is resistant to modification of the bowel program.
(Non-SCI patients: scientific evidence-one study in each of levels I, II, and V; grade of recommendation-A; strength of panel opinion-strong. SCI patients: scientific evidence-two studies in each of levels II and V, and one level III study; grade of recommendation-B; strength of panel opinion-strong).
Surgical and Nonsurgical Therapies
- Biofeedback is not likely to be an effective treatment modality for most individuals with spinal cord injury.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- The decision about a colostomy or ileostomy should be based upon the results of specialized screening procedures and the individual's expectations. If surgery is decided upon, a permanent stoma is the best option.
(Scientific evidence-V; grade of recommendation-C; strength of panel opinion-strong).
- Proposed surgical changes in the anatomy of individuals with SCI should be reviewed with the individual and the interdisciplinary team. These considerations should include discussions of anesthesia, surgical and postoperative risks, body image, independence in self management after the procedure, and realization of the permanence of the procedure.
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
Education Strategies for the Neurogenic Bowel
- Educational programs for bowel management should be
structured and comprehensive; should consider the home setting and available
resources; and should be directed at all levels of healthcare providers,
patients, and caregivers. The content and timing of such programs will
depend on medical stability, readiness to learn, safety, and related
factors. An educational program for bowel management after SCI should
include
:
- Anatomy.
- Process of defecation.
- Effect of SCI on bowel function.
- Description, goals, and rationale of successful bowel program management.
- Factors that promote successful bowel management.
- Role of regularity, timing, and positioning in successful bowel management.
- Safe, effective use of assistive devices and equipment.
- Techniques for manual evacuation, digital stimulation, and suppository insertion.
- Prescription bowel medications.
- Prevention and treatment of common bowel problems, including constipation, impactions, diarrhea, hemorrhoids, incontinence, and autonomic dysreflexia.
- When and how to make changes in medications and schedules.
- Management of emergencies.
- Long-term implications of neurogenic bowel dysfunction.
- Economic analyses including cost-effectiveness and cost-utility analyses, of bowel management interventions and programs. Studies should meet currently accepted standards (Gold et al., 1996).
(Scientific evidence-none; grade of recommendation-expert consensus; strength of panel opinion-strong).
- Patient and caregiver knowledge of, performance of, and confidence in the recommended bowel management program should be assessed at each follow-up evaluation.
(Scientific evidence-none; grade of
recommendation-expert consensus; strength of panel opinion-strong).
Definitions
Hierarchy of levels of scientific evidence:
- Large randomized trial with definite results
- Small randomized trials with uncertain results
- Nonrandomized studies with concurrent controls
- Nonrandomized studies with historic controls
- Case series with no controls
Categories of the Strength of Evidence Associated with the Recommendation:
- The recommendation is supported by scientific evidence from properly designed and implemented controlled trials providing statistical results that consistently support the guidelines statement
- The recommendation is supported by scientific evidence from properly designed and implemented clinical series that support the guidelines statement
- The recommendation is supported by expert
opinion
