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CHHS15/051

Canberra Hospital and Health Services


Clinical Procedure
Bowel Assessment and Management (Adults, Adolescents,
Children, Infants and Neonates)
Contents

Contents ..................................................................................................................................... 1
Purpose....................................................................................................................................... 2
Scope .......................................................................................................................................... 2
Section 1 – Bowel assessment ................................................................................................... 2
Section 2 – Constipation............................................................................................................. 3
Section 3 – Administration of rectal suppository....................................................................... 5
Section 4 – Administration of enema......................................................................................... 6
Section 5 – Bowel washout – Adults .......................................................................................... 7
Section 6 – Bowel washout – Babies (Centre for Newborn Care) ............................................. 9
Section 7 – Flatus tube insertion – Adults................................................................................ 11
Section 8 – Manual evacuation of faeces ................................................................................ 12
Section 9 – Bowel management for patients in the community ............................................. 14
Section 10 – Bowel protocol for enteral and oral fed patients in Intensive Care Unit (ICU) ... 15
Section 11 – Instaflo® Bowel Management System – Intensive Care Unit .............................. 16
Implementation ........................................................................................................................ 20
Related Policies, Procedures, Guidelines and Legislation ........................................................ 20
References ................................................................................................................................ 20
Definition of Terms................................................................................................................... 22
Search Terms ............................................................................................................................ 22
Attachments ............................................................................................................................. 23
Attachment 1: Laxatives and aperients used in adults ........................................................ 24
Attachment 2: Bristol Stool Chart ........................................................................................ 26
Attachment 3: Neonatal bowel washout ............................................................................. 27
Attachment 4: Instaflo® troubleshooting guide................................................................... 29
Attachment 5: Instaflo® Product Features ........................................................................... 31

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Purpose

The purpose of this procedure is to provide clinicians with information on the safe and
effective bowel management of patients in the hospital and in the community setting.

This procedure provides clinicians with best practice information for assessment and
management of patients with bowel issues and for educating and supporting patients and
their carers.

Scope

The Bowel Assessment and Management Procedure describes practices which will be
performed by nurses, midwives, medical officers, physiotherapists and dietitians. New staff
or students (within their defined scope of practice) will be required to perform these skills
under the direct supervision of a competent practitioner.

Nurses, midwives, medical officers, physiotherapists and dietitians providing assessment,


education and clinical procedures must have current theoretical and clinical knowledge in
bowel management.

Assistants in Nursing (AINs) who have received training and are assessed as competent are
able to perform bowel care procedures under the direction of a registered nurse for a
designated patient in the community.

The general principle of management in a bowel routine is to provide predictable and


effective elimination and reduce evacuation problems and gastrointestinal complications.

Bowel management is multidimensional and requires a multidisciplinary approach. Referrals


to dietitians, physiotherapists, occupational therapists and specialist medical services can
provide additional advice and interventions to assist in promoting effective bowel
management. Consider referral to these services for patients who have poor nutritional
status, poor mobility and activity levels or sudden changes in bowel function.

Section 1 – Bowel assessment

Prior to intervention, a detailed bowel assessment is required in order to identify the


patient’s history and contributing factors to bowel dysfunction. Bowel assessment tools can
be found on the Clinical Record Forms Register.

Physical examinations can include:


 abdominal examinations - including bowel sounds, distension, masses, tenderness,
rigidity

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 Rectal examination- inspection and palpation for masses, anal and perianal fissures,
haemorrhoids, bleeding, prolapse, hard stool, anal and sphincter tone

Commence daily bowel record chart (for 14-28 days) to assist with assessment.
Document assessment and formulate action plan.

Adverse findings are to be referred to a medical officer for further investigations.

For assessment and management of faecal incontinence see Continence Assessment and
Management Clinical Procedure (insert link).

Consider referring patients (adults and children) with constipation, faecal incontinence and
other bowel issues to the Community Care Continence Service (via Community Health Intake
- ph 62079977) on discharge from hospital.
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Section 2 – Constipation

Constipation refers to difficulty or straining and infrequent bowel movements over an


extended period of time. Symptoms associated with constipation include hard/dry stool,
bloating and abdominal pain accompanied with a sense of incomplete evacuation.

Initial management of constipation is recommended as a combination of diet, fluids, exercise


and good toileting habits.

Diet, fluid and exercise


 Adults (19 years and over):
o Diet should contain 25-30 g of fibre from a variety of sources. A gradual increase in
fibre is recommended. As fibre is increased, fluid intake must also be increased to 2
litres per day.
o Total fluid intake should be between 2.1 L (female) to 2.6 L (male) per day, unless
otherwise specified by the patient’s medical officer. Encourage patients to take
regular amounts of fluid throughout the day, extra fluid is recommended in
summer.
 Children:
o Adequate intake of dietary fibre for infants, children and adolescents can be found
on the National Health and Medical Research Council website
(http://www.nrv.gov.au/nutrients)
o Recommended daily fluid intake is approximately 50-60mL/kg/day (water, juice,
cordial) plus fluids from other sources.
 Refer to a Dietitian for assessment as appropriate.
 For patients with spinal cord injury, the amount of fluid needed to promote optimal
stool consistency must be balanced with the amount needed for bladder management.
Adult patients with urinary catheters may drink 2 to 3 litres maximum per day. Adult

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patients who do intermittent self-catheterisation may require less fluid to fit with their
individual program, normally around 2 to 2.5 litres per day.
 Encourage regular exercise. Patients with mobility impairments may benefit from
exercises such as pelvic tilt, low trunk rotation and single leg lifts.
 Refer to Physiotherapist for mobility assessment and strengthening exercises as
appropriate.

Alert: Increasing dietary fibre for the treatment of constipation in end-of-life patients can
compound the problem. Use of softeners and/or stimulants should be considered.

Toileting Activities
 Encourage a prompt response to the call to stool, going to the toilet at a regular time
each day, eating or drinking approximately 30 minutes prior to toileting to stimulate the
gastrocolic reflex.
 An upright position is recommended during defaecation. Encourage patients to sit with
both feet supported, on a footstool, lean forward with straight back and rest elbows on
knees. Without straining, relax and widen the back passage, advise patients not to hold
their breath. When finished, advise the patients to draw up their back passage firmly.
 Where a patient is unable to sit, a left side-lying position while bending the knees and
moving the legs toward the abdomen is recommended.
 Patients with mobility impairments (and at risk of pressure areas) must have a padded
toilet seat or commode, with backrest, footrest and side rails.
 Refer to Occupational Therapist and/or Independent Living Centre as required for
assistance and advice.

Pharmacological interventions
 Laxatives/aperients are useful for short-term treatment of acute constipation, and may
only be recommended for long-term management of constipation by medical staff. If
organic disease is not the cause of constipation, pharmacological treatment is
appropriate on a short-term basis. It should be considered only after non-
pharmacological interventions have been unsuccessful (information on
laxatives/aperients used in adults can be found in Attachment 1).
 When administering rectal medication monitor the patient and check the effectiveness
of the medication.

Surgery
 Usually reserved for severe intractable disease resulting from slow colonic transit, the
most common procedure is a subtotal colectomy and ileo-rectal anastomosis or
colectomy resulting in permanent stoma.

Patient /carer education


Educate patients/carers about
 Wide range of normal bowel routines and symptoms related to abnormal bowel
evacuation

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 Diet, fluids, exercise and good toileting habits


 Safe and correct use of laxatives - encourage consultation with GP
 Change in bowel habits - significant or prolonged change in bowel habits should be
reported to the patient’s GP
 Safe, effective use of aids and equipment.

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Section 3 – Administration of rectal suppository

A suppository is inserted into the rectum and dissolves at body temperature. Suppositories
assist in the evacuation of faeces from the rectum; or are used to administer medication for
absorption through the rectal wall.

Equipment
 Suppository
 Water- soluble lubricant (eg KY gel or if patient is at risk of Autonomic Dysreflexia use
lignocaine 2% gel, 5 minutes prior to procedure) or water for glycerin suppository
 Bedpan, commode or toilet
 Disposable protective pad - blue sheet
 Personal protective equipment (PPE), disposable gloves, gown and safety eyewear

Procedure
1. Check authorised prescriber order (Medical Officer or Nurse Practitioner)
2. Inform patient of the procedure and obtain consent
3. Ensure client has emptied bladder to prevent discomfort
4. Ensure privacy and reduce anxiety
5. Perform hand hygiene by either hand washing or using alcohol based hand rub (ABHR),
don PPE
6. Assemble equipment
7. Assist the patient to adopt the left lateral position (to facilitate contact with rectal
mucosa for effective bowel action) with knees flexed, and blue sheet in place
8. Drape the patient with a sheet or blanket, withdraw sheet to expose the anal area.
9. Don gloves and use generous amount of lubricant
10. Perform Digital Rectal Examination (DRE)
11. Remove wrapping and lubricate suppository and insert beyond the anal sphincter and
against the rectal mucosa
12. Encourage patient to retain suppository for 15-20 minutes lying in the left lateral
position
13. Assist patient onto bedpan, commode or toilet if necessary
14. Observe the amount and nature of the bowel motions (use Bristol Stool Chart as a
guide)
15. Undertake DRE if in doubt to assess outcome
16. Discard waste appropriately

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17. Remove gloves and other PPE


18. Perform hand hygiene
19. Document in clinical record

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Section 4 – Administration of enema

An enema is introduced into the rectum or lower colon with the purpose of producing a
bowel action or instilling medication.

There are two main types of enemas:


 Evacuant: Used to evacuate the bowel. They may be small or large volume and are
usually commercially prepared
 Retention: A solution used primarily for local effects, to be retained for a specific period

Equipment
 Appropriate enema at room temperature
 Water- soluble lubricant (e.g. KY gel or if at risk of Autonomic Dysreflexia use lignocaine
2% gel, 5 minutes prior to procedure) or water for glycerin suppository
 Bedpan, commode or toilet
 Disposable protective pad - blue sheet
 Protective equipment (PPE)

Procedure
1. Check authorised prescriber order (Medical Officer or Nurse Practitioner)
2. Inform patient of the procedure and obtain consent
3. Ensure patient has emptied bladder, to prevent discomfort
4. Ensure privacy and reduce anxiety
5. Perform hand hygiene, don PPE
6. Assemble the equipment
7. Assist the patient to adopt the left lateral position (to facilitate contact with rectal
mucosa for effective bowel action) with flexed knees and blue sheet in place
8. Drape the patient with a sheet or blanket, withdraw sheet to expose the anal area
9. Don gloves and use generous amount of lubricant
10. Perform Digital Rectal Examination (DRE)
11. Remove cap from enema and lubricate nozzle
12. Encourage client to relax
13. Part the buttocks. Gently insert the enema tip 5cm into rectum
14. Slowly squeeze content into rectum
15. Maintain pressure on the enema tube to prevent flow back of liquid returning to the
tube while removing nozzle from rectum
16. Encourage patient to retain enema for 15-20 minutes lying in the left lateral position
17. Assist patient onto bedpan, commode or toilet if necessary

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18. Observe the amount and nature of the bowel motions, use Bristol Stool Chart as a guide
(see Bristol Stool Chart in Attachment 2)
19. Undertake DRE if in doubt to assess outcome
20. Discard waste appropriately
21. Remove gloves and other PPE
22. Perform hand hygiene
23. Document in clinical record

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Section 5 – Bowel washout – Adults

Bowel washouts are performed with the purpose of:


 Stimulating peristalsis and remove faeces or flatus
 Cleanse the colon and rectum in preparation for an examination or a surgical procedure
 Remove toxins from the large intestine
 Soften faeces and lubricate the rectum and colon

Equipment
 Bowel washout solution as ordered
 Irrigation set (can, rubber tubing, and clamp) or coloplast irrigation set
 Medium ‐ medium connector
 Disposable rectal catheter or short length, female Foley’s catheter
 Lubricant
 Personal protective equipment (PPE) including, clean gloves, gown and protective
glasses, goggles or shield
 Absorbent underpad
 Clinical waste receptacle
 General waste receptacle
 Bedpan or commode
 Intravenous (IV) pole/stand

Procedure
1. Check authorised prescriber order (Medical Officer or Nurse Practitioner)
2. Explain the procedure and obtain consent
3. Ensure Privacy
4. Perform hand hygiene, don PPE
5. Assist the patient to assume the left lateral position
6. Cover the patient with a sheet
7. Attend hand hygiene by either hand washing or using ABHR, don PPE
8. Prepare equipment
9. Ensure the solution is at body temperature
10. Connect the can, rubber tubing and rectal catheter or coloplast irrigation set
11. Suspend the can from the IV pole for priming
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12. Attend hand hygiene by either washing hands or using ABHR


13. Don clean gloves
14. Inspect the anus for the presence of haemorrhoids, bleeding or irritation
15. Pour approximately 240mL of solution into the can
16. Expel air from the tubing, then clamp
17. Apply lubricant to the catheter (liberally)
18. Ask the patient to breathe deeply
19. Part the buttocks
20. Inform the patient when the catheter is inserted
21. Gently introduce the rectal catheter approximately 7-10cm into the rectum
22. Allow the solution to flow into the rectum, holding the can 30-45cm above the level of
the patient’s buttocks

Note: If the patient complains of pain, exhaustion or great discomfort during the procedure,
cease the flow of solution for a few minutes then slowly recommence. Hold the irrigation
can no higher than 44cm above the level of the patient’s buttocks.

23. When the solution has been instilled into the rectum, clamp the tube
24. Disconnect the can and hold the tube over the bedpan, unclamp the tube
25. When the solution flow ceases, clamp the tubing
26. Reattach the can and repeat the procedure with a further 240mL of solution
27. Continue the procedure until the return is clear
28. When the last of the solution has been siphoned from the rectum, remove the catheter
29. Clean the anal area
30. The patient may sit on a bed pan
31. Discard disposable equipment and gloves into clinical waste receptacle
32. Attend hand hygiene by either washing hands or using ABHR
33. Disassemble equipment
34. Clean appropriately
35. Remove safety glasses or goggles and gown
36. Perform hand hygiene using either soap and water or ABHR
37. Observe amount and nature of return
38. Document on the patients medication chart
39. Document in clinical record:
 Amount of solution instilled
 Patient’s reaction to the procedure
 Amount and nature of return

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Section 6 – Bowel washout – Babies (NICU/Special Care Nursery)

NOTE: This is a guide only and will vary between guidelines from Paediatric Surgeons

This procedure is used for rectal or distal stoma washouts:


1. To clean the distal portion of the bowel, decompress the bowel and deflate the
abdomen by removing air and faeces. Bowel washouts facilitates surgery and has been
shown to prevent or reduce the risk of post operative enterocolitis and as such can be
used as a mode of temporary management in proven cases of Hirschsprung’s until
definitive surgery – which may be 4 – 12 weeks depending on each case.
2. To relieve low intestinal obstruction due to meconium plug, meconium ileus or intestinal
dysmotility of prematurity

Assessment:
Physical: Assess and record any signs of bowel obstruction. These include:
 Vomiting – note the frequency, colour and amount. Is it bile stained?

NOTE: Green bile staining indicates bowel obstruction, if present notify medical team
immediately.

 Abdominal distension
o Is the abdomen tight or shiny?
o Determine and record degree of distension of the abdomen prior to performing
bowel washout
 Bowel action
o Time since last bowel action
o Note – frequency, consistency, colour and +/- blood

Equipment
 Trolley
 60 mL catheter tip syringe
 Sodium Chloride 0.9% or solution as prescribed – warmed to body temperature
 Nelaton urine catheters – soft – less likely to damage mucosa (do not use nasogastric
tubes with weighted tips)
 Lubricating gel
 Kidney dish
 Disposable wipes
 Disposable gloves
 Disposable sheet
 Nappies
 Clinical waste receptacle
 Alcohol based hand rub

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Procedure
Medical orders for the bowel washout must be written clearly on the patient’s care plan by
the surgical team or Neonatologist. Orders should be clearly documented and include:
 Frequency
 Size and length of catheter to be inserted (see table below)
 Volume of sodium chloride 0.9% to be used – maximum per procedure 20mL/kg
 Administer acetylcysteine if required, according to medical order

For babies with Hirschsprung’s disease a catheter will be inserted and taped insitu by the
Paediatric surgeon. Note length of catheter on return to ward. Do not remove the catheter,
notify surgeon if there is any change in the length or if the catheter is dislodged.

Weight Size (Guide only-please refer to Length to be inserted


Paediatric surgeon notes)
Less than 2 kg Size 8 FG Feeding tube or 2 – 3 cm
Nelaton
Greater than 2 kg Size 8 FG Feeding tube or 5 cm
Nelaton

1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Explains procedure to parent and gain consent
3. Position the infant on back with legs in a frog position on a clean nappy and disposable
sheet
4. Prime the catheter with sodium chloride 0.9% or other solution as prescribed
5. Lubricate the tip of the catheter with lubricating gel
6. Gently insert catheter into rectum or into distal stoma
Do not use excessive force if resistance is felt
7. Instil solution in 10 –20 mL aliquots over 1-2 minutes. There should be no resistance
while injecting the sodium chloride 0.9%
Do not pull back on syringe to aspirate. Allow the sodium chloride 0.9% to run out
naturally
8. Remove syringe and let fluid run into nappy / kidney dish
9. Repeat procedure until return is clear
10. Remove catheter
11. Ensure infant is left clean and dry
12. Discards all waste in bin
13. Attend hand hygiene following procedure by either hand washing or using ABHR
14. Document the results of bowel washout on fluid balance chart, the bowel washout care-
plan and in the patient’s notes
15. Report abnormal findings immediately
16. Watch for signs of increasing abdominal distension, tenderness and any features
suggestive of perforation
17. In preterm infants there is a risk of re-absorption of sodium chloride 0.9%, especially if
most of the solution is not expelled

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NOTE: Use only sodium chloride 0.9% solution – the use of other solutions or concentrations
in this patient group may be dangerous.
May need regular monitoring of serum sodium as there is a risk of reabsorption especially in
preterm infants.

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Section 7 – Flatus tube insertion – Adults

A flatus tube can be inserted to relieve abdominal distension due to flatus. The insertion of a
flatus tube will be prescribed by a Medical Officer. The procedure can be performed by a:
 Medical Officer.
 Registered Nurse.
 Enrolled Nurse.
 Student under the direct supervision of a Registered Nurse.

Rectal stimulation can cause bradycardia due to vagal nerve stimulation, assess the patient’s
heart rate before, during and after the procedure.

Equipment
 Rectal tube
 Lubricant
 Disposable dish
 Disposable protective pad - blue sheet
 Draw sheet
 Protective glasses, safety goggles or shield
 Tape measure

Procedure
1. Check Medical Officer order
2. Inform patient of the procedure and obtain consent
3. Ensure privacy
4. Perform hand hygiene, don PPE
5. Prepare equipment
6. Measure abdominal girth
7. Assist the patient to assume the left lateral position, with underpad in place. Cover the
patient with a drawsheet
8. Attend hand hygiene
9. Assess the patient’s pulse before examination
10. Don gloves and protective glasses
11. Expose the anal area and inspect for haemorrhoids, bleeding or irritation
12. Lubricate the tip of the rectal tube
13. Place the distal end of the tube underwater
14. Position the dish near the anal area

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15. Encourage the patient to breathe deeply


16. Part the buttocks and gently insert the rectal tube approximately 5-8cm into the rectum
17. Leave the rectal catheter in place for the prescribed time
18. Observe for air bubbling and reduction in abdominal distension

NOTE: Cease the procedure if the patient experiences pain. The rectal catheter can be left in
place for a maximum of 20 minutes only

19. Remove the rectal catheter once the air bubbles cease
20. Clean the anal area
21. Discard equipment, remove gloves, attend hand hygiene
22. Measure abdominal girth
23. Ensure patient is left comfortable
24. Assess the patient’s pulse after examination
25. Document in clinical record:
o Record results of flatus tube insertion
o Note the patient’s level of comfort/discomfort post procedure
o Measure and record decrease in abdominal distension

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Section 8 – Manual evacuation of faeces

 Manual evacuation may be used for patients with lower motor neurone bowel
dysfunction (e.g. spinal cord injury (SCI) below T12) as destruction of the sacral reflex
defecation centre results in loss of defecation reflex. In patients with lower motor
neurone bowel dysfunction (areflexic bowel) the main goal is to encourage a firm,
formed stool that can be retained between bowel care sessions and easily evacuated.
 In those patients with a spinal cord injury above T6 manual evacuation may need to be
attended if the patient is experiencing an episode of Autonomic Dysreflexia and the
cause of Dysreflexia is an overextended rectum/full lower bowel. Extreme caution and
specific interventions are required as per the ‘Treatment Algorithm for Autonomic
Dysreflexia (Hypertensive Crisis) In Spinal Cord Injury’, the algorithm can be accessed
via the link:
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#
zoom=100
 Manual Evacuation may need to be attended when impacted stool in the rectum is
unable to be removed in any other way. This is sometimes required for patients with
neurogenic bowel changes associated with diseases such as Multiple Sclerosis and
Parkinson’s disease.
 In other patients (patients without neurogenic bowel dysfunction), manual evacuation
of faeces is seen as a last resort management where all other methods of bowel
evacuation have failed.

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 Manual removal also may be needed to remove stool prior to the insertion of a
suppository or enema for the medication to be effective.

In consultation with the Medical Officer, establish that there are no contraindications that
may place patients ‘at risk’. Examples include, but are not limited to:
 Cardiac conditions with arrhythmias (stimulation of the vagus nerve in the rectal wall
can slow the patient’s heart rate)
 Bowel perforation, rectal bleeding or anal fissures
 Distress, pain, discomfort, bleeding or anti clotting medication
 Recent rectal/anal surgery or trauma

Equipment
 Water- soluble lubricant (for patients with spinal cord injury at or above T6 use
lignocaine 2% gel, 3-5 minutes prior to procedure)
 Personal protective equipment (PPE), disposable gloves, gown and safety eyewear
 Disposable protective pad - blue sheet
 Bedpan or collection container

Procedure
1. Inform patient of the procedure and obtain consent
2. Ensure that patient has emptied bladder
3. Ensure privacy
4. Perform hand hygiene, don PPE
5. Assist the patient to adopt the left lateral position with knees flexed, and blue sheet in
place
6. Drape the patient with a sheet or blanket and withdraw sheet to expose the anal area.
Don gloves.
7. Lubricate index finger and anus generously with lubricating gel
8. Encourage patient to relax (breathe regularly)
9. Part buttocks and insert the gloved finger into the rectum slowly and gently
10. If stool is solid mass, push finger into the centre, split it and remove small sections until
none remains. If small hard stool, remove a lump at a time.
11. Patients may assist by performing valsalva manoeuvre. Patients with areflexic bowel or
lower motor neurone bowel dysfunction may respond to the Valsalva manoeuvre during
manual removal to assist with bowel emptying. (Valsalva manoeuvre is holding the
breath and forcibly trying to exhale against a closed glottis, thereby creating raised
intra-abdominal pressure and a bearing-down effect)
12. Document in clinical record

NOTE: Valsalva manoeuvre should not be performed on a patient with a full bladder due to
risk of vesico-ureteric reflux. It is also contraindicated for individuals with cardiac problems
and hypertension.
With prolonged straining, valsalva can also predispose to haemorrhoids and rectal prolapse
over time.

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Section 9 – Bowel management for patients in the community

 Routine bowel care is not a clinical service provided by the ACT Health, RACC,
Community Care Program (CCP) Nursing Service as it is considered an ‘activity of daily
living’. Non Government Organisations provide routine bowel care as part of a personal
care package.
 An exception to this are Assistants in Nursing (AINs) employed by ACT Health, RACC,
who provide personal care for a ventilator dependent patient in the community. AINs in
the community attend to bowel care under the direction of a registered nurse.
 CCP nurses offer assessment, advice and review of bowel regimes. CCP nurses will only
administer short-term rectal medication if a medical order is in place and will only
perform digital rectal examination for the purpose of assessment.
 The left lateral position is recommended for most bowel interventions. Where there is a
clinical reason why the left lateral position can’t be adopted by the patient, an
alternative safe ergonomic recommendation is to be implemented following manager
approval. The recommended procedure is to be clearly documented in the care plan and
progress notes
 CCP nurses should consult with the CCP Continence Clinical Nurse Consultant (CNC) as
required.

When caring for patients with a spinal cord injury at or above T6 community nurses will
ensure the patient and their carers are educated about the risk factors, signs and symptoms
of autonomic dysreflexia. The admitting nurse will ensure that an appropriate management
plan is in place for bladder and bowel care, and that medical orders for catheter insertion
and medication administration are documented in the patient file. The emergency
management plan will be documented in the patient’s file and the patient and their carers
are made aware of the plan.

The ‘Treatment Algorithm for Autonomic Dysreflexia (Hypertensive Crisis) In Spinal Cord
Injury’ is followed in the event of Autonomic Dysreflexia and can be accessed via the link:
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#zoo
m=100

In those patients with a spinal cord injury above T6, manual evacuation may need to be
attended to if the patient is experiencing an episode of Autonomic Dysreflexia and the cause
of the Dysreflexia is an over distended rectum/full lower bowel. Extreme caution and specific
interventions are required to manage this and the ‘Treatment Algorithm for Autonomic
Dysreflexia (Hypertensive Crisis) In Spinal Cord Injury’ must be followed.

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Section 10 – Bowel protocol for enteral and oral fed patients in Intensive
Care Unit (ICU)

This protocol does NOT apply to the following patients:


 Those with signs and symptoms of bowel obstruction (abdominal discomfort and
distention, nausea and vomiting)
 Those excluded by the ICU medical team
 Recent gastro intestinal surgery
 Spinal injury patients

Procedure
1. Once enteral or oral diet has been started consult doctor to prescribe:
 Macrogol 3350 (Movicol®) ONCE daily (dissolved in 125 mL water)
 Docusate/senna 50mg/8mg (Coloxyl® & Senna) TWO tablets TWICE daily
 40mL warm water THREE times daily via enteral tube
If bowels open within 3 days of commencing protocol continue step 1
If bowels NOT open within last 3 days on protocol progress to step 2

2. Rectum Full
Continue step 1 and consult doctor to prescribe:
 ONE bisacodyl and TWO glycerin suppositories
If bowels open go back to step 1
If bowels NOT open within 24 hrs go to step 3

Rectum empty
Continue step 1
Observe for signs & symptoms of bowel obstruction
Inform doctor regarding unopened bowels & empty rectum

3. Continue step 1 and consult doctor to prescribe phosphate enema (Fleet® Enema)
If bowels open return to step 1
If bowels NOT open within 24 hrs go to step 4

4. Consult doctor for repeat phosphate enema (Fleet® Enema) and increased aperients +/-
manual evacuation
If bowels opened return to step 1
If bowels NOT open continue step 4 every 24 hrs until bowels have opened

Diarrhoea
If diarrhoea occurs (3 large liquid stools within 24 hours) withhold oral aperients for 24 hours
then recommence bowel protocol at Step 1.
If diarrhoea persists cease macrogol 3350 (Movicol®) and then reduce docusate/senna
50mg/8mg (Coloxyl® & Senna) to 2 tablets ONCE daily.

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Record frequency & type of bowel motion in Metavision on the ICU flow chart and the fluid
balance chart, using the Bristol Stool Chart (see attachment 2)
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Section 11 – Instaflo® Bowel Management System – Intensive Care Unit

The Instaflo® Bowel Management System is used in the Intensive Care Unit when patients
are assessed as having Bristol type 7 (watery) stools.

The Instaflo® aims to:


 reduce excoriation from faecal incontinence
 prevent risk of infecting wounds (e.g. pressure ulcers, burns, grafts)
 reduce the risk of infection to other patients and health care professionals

A medical officer must prescribe the use of the Instaflo®.

The registered nurse must perform an initial assessment to determine if the patient meets
criteria for use of the Instaflo. The following indications and contraindications will be
considered:

Indications
 patients requiring faecal diversion for the protection of wounds, burns, flaps or grafts
 patients with infectious stool (eg. VRE, MRSA, C. difficile)
 minimising risk of excoriation from faecal incontinence in diarrhoea not controlled by
medical therapy

Contraindications
 The bowel management system should not be used for patients who have had previous
colorectal surgery involving an anastomosis, or who have had any rectal surgery or
recent anal or sphincter reconstruction
 Do not use for the patient with impacted stool
 Do not use if the patient’s distal rectum cannot accommodate the inflated volume of
the retention cuff or if the distal rectum/anal canal is severely strictured secondary to
tumour, inflammatory condition, radiation injury or scarring
 Do not use for patients who have a known sensitivity or allergy to the materials used in
the device

Before using The Instaflo®


 The bowel management system should be ordered by a medical officer and documented
in the patient’s medication chart and medical notes
 The bowel management system is available in 2 catheter sizes either 4cm or 6cm (6cm is
the most frequently used adult size)
 The colon and rectum should be clear of all stool/faecal matter prior to insertion of the
bowel management system
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ALERT:
A stool management protocol should be in place for patients who have had insertion of the
bowel management system for skin/wound protection. This is to ensure that the stool
remains soft enough to ensure flow and prevent blockage until such time that contamination
is not longer a risk.
The protocol will be ordered by the medical team and reviewed daily.

Tips for inserting the Instaflo®


 The catheter tip is folded and inserted into the rectum and attached to a large capacity
drainage bag via a wide flexible connector tubing
 The retention cuff (Blue Connector) is inflated with water, after insertion of the
catheter, to provide retention of the catheter in the rectum
 A flush/sample port is located on the drain tube and provides access for catheter
flushing and stool sampling. (see picture below)
 If stool is not flowing into the catheter, irrigate the catheter. Fill the Luer syringe with
water, connect the syringe to the CLEAR connector (IRRIG), and slowly depress the
plunger. WARNING: Verify connection to correct catheter connector

Precautions during use


 If patients develop rectal bleeding, assess for pressure necrosis from the catheter then
discontinue use
 Patients with weak sphincter function may expel the catheter or may have increased
leakage of stool
 Do not insert anything into the anal canal with the catheter such as suppositories or
thermometers
 Do not allow ointments that contain petroleum (e.g. Vaseline®) to come into contact
with catheter as they may damage the catheter
 The following adverse events may be associated with the use of any rectal device:
o Infection
o Leakage of faecal content
o Perforation
o Pressure necrosis
o Obstruction or loss of sphincter tone

Equipment
 Instaflo® bowel management system (Catheter kit which includes silicone catheter,
collection bag, inflation syringe, and lubricant)
 Personal protective equipment (PPE) gown, gloves, goggles (additional protective
equipment may be required for patients with infective faeces)
 Extra water soluble lubricant
 Yellow contamination waste bag
 Humidified water/sodium chloride 0.9% and plain IV giving set/ enteral feeding set for
irrigation of the rectum
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Procedure
1. Explain the procedure to the patient, where plausible obtain consent, provide pain relief
if necessary
2. Attend hand hygiene, put PPE on. It is advisable to double glove for the rectal
examination
3. Place patient in left lateral position
4. Examine the rectum for faecal impaction and clear any stool present. Feel for any mass,
lesion or stricture which may preclude the use of the device. Check the length of the
anal canal during rectal examination, as this will determine catheter size. Typically, most
patients will require a 6cm catheter but a short anal canal will necessitate a 4cm
catheter (which must be ordered specifically)
5. Prior to use, verify proper inflation and deflation of catheter cuff and balloon and check
patency of the irrigation lumen
6. Connect end of catheter drain tube to collection bag and twist clockwise to lock in place.
Clamp and secure collection bag drain tube. Insert drain plug
7. Lubricate the end of the catheter well and fold in half
8. Grasp the lubricated catheter directly behind the retention cuff with double lumen
connector tubing oriented anteriorly. At the time of maximum sphincter relaxation,
insert the balloon end of the catheter into the distal rectum. Maintain anterior
orientation of double lumen connector tubing throughout insertion
9. Fill retention cuff via blue connector with 35-40mL of water. Disconnect the syringe
10. Confirm catheter is tension free
11. Secure catheter, by anchor straps to the patient’s buttocks (Use hydrocolloid strip to
protect skin then use tape to anchor straps)
12. Hang catheter bag so that the catheter drain is not twisted or kinked
13. Use sheet clip to secure drain tube
14. If patient’s condition permits, tilt the whole bed slightly upward, as this encourages
drainage by gravity

Confirming Placement
To confirm placement, gently tug and release to seat the cuff
If no noticeable stool is in the fluid draining from the patient, alternately squeeze and
release the drain tube to manually douche the patient. This may help break up the large
stool piece. Refer to “Insertion of the Instaflo®” to clarify how to irrigate

The Instaflo® should be flushed at least twice a day.


1. If tolerated, position the patient’s bed to enable retention of fluid in rectum (i.e. foot
end of bed elevated approx 20-30 degrees. The patient’s head can remain slightly
elevated. If using an inflated air mattress, inflate to maximum level. The patient will
remain in this position for the duration of the irrigation. Placing the patient in the left
lateral position during irrigation may improve fluid retention
2. Verify that the drainage bag can hold another 2 litres of fluid. If not empty bag prior to
commencing irrigation
3. Fill irrigation bag with 100mL of luke warm water and hang 1 metre above anus
4. Connect irrigation bag administration set (IV giving set) to white capped clear connector
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5. Open flow control valve on irrigation bag and allow fluid to drain by gravity into the
rectum and colon
6. Open flow valve on irrigation bag and allow fluid to drain by gravity into the rectum and
colon. If fluid leaks around the tube, gentle traction on the drain tube may reduce
leakage. If leakage persists, check the retention balloon (BLUE connector) volume and
add another 10mL of air to the retention. DO NOT EXCEED 40MLS
7. If possible leave the irrigant fluid in situ and patient in position for 5-10 minutes
8. Connect syringe to the blue connector and completely aspirate the 20mL of air and
allow irrigant to drain
9. After irrigation is complete, disconnect administration set from white capped port and
close cap
10. Return patient to pre procedure position
11. Milk all remaining faeces and irrigant from the catheter

Ongoing Maintenance
1. Strictly adhere to stool modification plan and irrigation protocol
2. Ensure that the tapes are securely attached to patient’s buttocks at all times (White ETT
tape may be tied around the patient’s hips if the buttocks are excoriated)
3. Ensure there is no excessive prolonged traction on the catheter or that the catheter is
not occluded due to twisting or patient lying on the tube
4. Inspect the catheter near the anus to ensure that stool or irrigation fluids are not sitting
in the catheter. If present milk the drainage tube
5. Assess patient’s perineal region for mucous or stool leakage, if present clean
6. Excessive leakage may be secondary to catheter occlusion with stool. Catheter removal
and reinsertion may be required
7. Flush tubing if required with 50mL of water to prevent faeces building up in the tube
8. Verify retention cuff volume every 7 days by aspirating all of the water from the cuff and
perform a digital examination of the rectum
9. Document observations on GIT tab on MetaVision to ensure continuity of care (previous
name Zassi)
10. Change catheter every 29 days
11. Please see attachment 1 for trouble shooting ideas if there are any concerns

Catheter Removal
1. Explain the procedure to the patient
2. Apply gloves, goggles and gown
3. If tolerated, place the patient in a left lateral knee-chest position. Pain relief may be
required prior to position change
4. Deflate catheter retention cuff by connecting syringe to (Labelled CUFF) and aspirating
all water from retention cuff. Disconnect syringe. Verify deflated state of retention cuff
by confirming pilot balloon collapse
5. Ask the patient to push down gently to expel the catheter
6. If catheter does not come out easily, repeat steps after applying water-soluble lubricant
to anal canal
7. Perform a visual inspection of the rectum post removal
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For Instaflo® troubleshooting guide and product features - see attachment 4 and 5.

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Implementation

This procedure will be communicated to relevant staff via team meetings, and will be
incorporated into existing education and training programs.

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Related Policies, Procedures, Guidelines and Legislation

 Nursing and Midwifery Continuing Competence Policy and Standard Operating


Procedure, Document Number DGD12-050
 Autonomic Dysreflexia Community Care Program Standard Operating Procedure,
Document number CHHS13/250
 CHHS Clinical Procedure: Continence Assessment and Management, Document Number
CHHS14/033

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References

1. Australian and New Zealand Spinal Cord Society (ANZSCOS), September 2010

2. Chew, S. Peer reviewed Clinical Update: Obstructed Defaecation Australian and New
Zealand Continence Journal, Volume 13 Number 2. 2007.

3. Clinical Guidelines for Digital Rectal Examination, Manual Removal of Faeces and
Insertion of Suppositories /Enemas for Adult Care only. NHS.2012.

4. Coggrave, M. Transanal Irrigation for bowel management, Nursing Times. 2007.

5. Coggrave, M. Norton, C. The need for manual evacuation and oral laxatives in the
management of neurogenic bowel dysfunction after spinal cord injury:
International Spinal Cord Society 48,504-510. 2010.

6. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Neurogenic Bowel
Management In Adults with Spinal Cord Injury: Paralysed Veterans of America,
Washington. 2010.

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7. Emmanuel, A. Review of the efficacy and safety of transanal irrigation for neurogenic
bowel dysfunction. International Spinal Cord Society. 48, 664-673. 2010.

8. Furusawa, K. Tokuhiro, A. and Sugiyama, H. Incidence of symptomatic autonomic


dysreflexia varies according to the bowel and bladder management techniques in
patients with spinal cord injury. International Spinal Cord Society Cord 49, 49-54. 2011.

9. Goetz, L Transanal Irrigation or conservative bowel for clients with spinal-cord injury?
Nature Clinical Practice Gastroenterology & Hepatology (4):256-257. 2007.

10. Treatment Algorithm for Autonomic Dysreflexia (Hypersensitive crisis) in Spinal Cord
Injury. 2010.
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155143/algorithm.pdf#
zoom=100

11. Kerr, J (Physiotherapist and Ergonomist). Ergonomic assessment of bowel care


management in community setting, 2007.

12. Krassioukov, A. Eng, J. and Claxton, G. Neurogenic bowel management after spinal cord
injury. International Spinal Cord Society 48 (10): 718-33. 2010.

13. Management of lower bowel dysfunction, including DRE and DRF Royal Collage of
Nursing guidance for nurses 2012.

14. Namirah, J. Zone-En, L. and Olden, K. Diagnostic Approach to Chronic Constipation in


Adults. American Family Physician. 2011. www.aafp.org/afp

15. National Guideline Clearinghouse, Practice Guidelines for the Management of


Constipation in Adults. 2010.

16. Norton, C and Chelvanayagam, S. (2004) Bowel Continence Nursing. Beaconsfield


Publishers, Ltd., U.K.

17. Queensland Spinal Cord Injuries Service: Bowel Management Following Spinal Cord
Injury. 2012.

18. Rogers, J. How to manage chronic constipation in adults. Nursing Times: 108 (41): 12, 14
16. 2012.

19. St. Mark’s Hospital and Academic Institute Bowel Control. Constipation. 2010.

20. The Joanna Briggs Institute. Management older Constipation for Older Adults. Best
practice Vol 12(7):1- 2008.

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21. McWilliams D, 2010, Rectal irrigation for patients with functional bowel disorders,
Nursing Standard Vol 24, No 26 March.

22. Sutcu, S. The prevention and management of faecal incontinence. (2007). The Journal of
Stomal Therapy Australia. (27)4. 10-11. Retrieved from:
http://www.stomaltherapy.com/documents/JSTA_December_2007.pdf

23. Zassi Bowel Management System (2003) Instructions for Use, Fernandina Beach, USA.

24. The Royal Children’s Hopital Melbourne Clinical Guidelines: Bowel washout (Rectal).
http://www.rch.org.au/rchcpg/index.cfm?doc_id=9220. 17th October 2011.

25. National Health and Medical Research Council – Nutrient Reference Values for Australia
and New Zealand (2006).

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Definition of Terms

Hirschsprung’s Disease: A rare disorder of the bowel, most commonly of the large bowel
(sometimes called megacolon), where there is a lack of nerves, known as ganglion cells in
the bowel wall. This prevents effective peristalsis and results in intestinal obstruction. It
affects four times as many boys as girls with an increased incidence in infants with Down’s
syndrome.

Meconium Plug: This condition is the most common and mildest form of mechanical distal
obstruction of the newborn. Inspissated and immobile meconium causes a transient form of
distal colonic or rectal obstruction. The aetiology of this disorder is unclear. It is most
common in preterm infants.

Meconium ileus: The obstruction is mainly caused by thick tenacious meconium. This stick
meconium is unable to be propelled through the intestine, usually the gut is not damaged
and continuity is not disrupted. Meconium ileus occurs in 15% of infants with Cystic Fibrosis.
In others the condition is associated with volvulus, atresia or perforation.

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Search Terms

Bowel Washout, Rectal administration, Enema, Suppository, Flatus tube, Manual evacuation,
Instaflo, Intensive Care Unit, Adults, Adolescents, Children, Infants and Neonates

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Attachments

Attachment 1: Laxatives and aperients used in adults


Attachment 2: Bristol Stool Chart
Attachment 3: Neonatal Bowel Washout
Attachment 4: Instaflo® Troubleshooting guide
Attachment 5: Instaflo® Product Features

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for
its own use. Use of this document and any reliance on the information contained therein by any third party is at
his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By


Eg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment 1: Laxatives and aperients used in adults

Bulk forming Act by retaining water and promoting microbial growth in the colon. This
laxatives increases faecal bulk, which in turn stimulates peristalsis
e.g. bran, psyllium
(Metamucil®), Takes 48-72 hours to have an effect (due to transit time) so are not suitable
sterculia for the treatment of acute constipation
(Normacol®)
Useful to help ensure regular bowel actions and avoid chronic constipation

Start with a small dose taken regularly and wait at least 2 or 3 days for signs
of improvement. Increase gradually until an effective dose is reached

Bloating is the most common short-term side effect

Care must be taken when adding fibre to ensure adequate increase in fluids.
Patients may develop spurious diarrhoea as a result of constipation and
faecal impaction from an increase in fibre, and be misdiagnosed with
diarrhoea and thus treated incorrectly, compounding the problem.
Patients with actual or suspected intestinal obstruction, low fluid intake or
swallowing difficulties should avoid these laxatives.
Stimulant laxatives Act on the nerve plexuses in the gut wall causing irritation and increasing
e.g. bisacodyl peristalsis in the small and large bowel
(Durolax®),
(Bisalax®), senna Abdominal cramping may be increased if the stool is hard and a stool
(Senokot®),glycerin softener may be used in combination with this group

Takes 6 to 12 hours to act after oral administration or 15 to 30 minutes after


rectal administration. Neurogenic bowel has a slower transit time so oral
medication will often take longer to have an effect

In PR administration, the suppository must come into contact with the mucus
membrane to ensure maximal effectiveness

A bisacodyl (Bisalax®) enema acts as a chemical stimulant to the bowel,


stimulating reflex action, but may be damaging to the bowel with long-term
use

A glycerin suppository acts as a very mild local stimulus and lubricating agent.
It forms a gel that lubricates and softens the faeces allowing the stool to be
evacuated with minimal side effects

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Faecal softeners Act by lowering the surface tension of faeces, which allows water to
e.g. docusate penetrate and soften the stool. They may also have a weak stimulatory effect
sodium (Coloxyl®), and are often given in combination with a chemical stimulant
Liquid paraffin
(Agarol®), Microlax® For the drugs to be effective, the patient needs to drink at least 1 to 2 litres
enemas of fluid per day

Takes 24 to 48 hours for effect if taken orally or 15-30 minutes after rectal
administration

A Microlax® enema liberates the water that is present in faeces. This action
causes softening of the stool, resulting in easier elimination
Osmotic laxatives Lactulose acts by lowering colonic pH through the generation of fatty acids
e.g. lactulose, and fermentation products. Faecal weight, volume and water are significantly
sorbitol (Sorbilax®), increased. Fluid intake is important, as patients may become dehydrated. It is
macrogol 3350 administered orally and may take from 24 to 48 hours to work
(Movicol®,
Osmolax®, Macrogol 3350 (Movicol®, Osmolax® and ClearLax®) has an osmotic effect in
ClearLax®) the gut, causing a laxative effect. Each sachet should be dissolved in 125mL
water

Are effective for the relief of chronic constipation and faecal impaction
Tolerated by patients with renal disease and impaired cardiac function
Saline laxatives Have an osmotic effect causing an increase in intraluminal volume and also
e.g. sodium stimulate intestinal motility
phosphate enemas
(Fleet®) Fast acting, resulting in bowel movements in 1 to 3 hours after oral
administration

Sodium phosphate products are available for rectal enemas and take 5 to 15
minutes to work generally

Can be used to empty the large bowel prior to surgery or investigation


Can cause electrolyte disturbances and dehydration

Sodium phosphate enema should not be used routinely for patient with
spinal cord injuries.
Any full size enema (Fleet®) used on a regular basis can cause problems with
dependency. Patients may not be able to retain the enema for it to be
effective, over distension of the bowel may stimulate Autonomic Dysreflexia.

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Attachment 2: Bristol Stool Chart

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Attachment 3: Neonatal bowel washout

NEONATAL BOWEL WASHOUT (rectal or distal stoma)

DATE: ______________________________________________________________

DIAGNOSIS: ________________________________________________________

AIM: To relieve distension and allow regular passing of stools

Recommendations Medical Orders (please fill in blanks or Medical


circle appropriate order) Officers
initials

Frequency Daily BD TDS Other: ______

Location – via rectum or rectum distal stoma


distal stoma

Size and depth of soft as per Paediatric surgeon instructions


Nelaton urine catheter
< 2 kg 10 FR – 2 – 3 cm < 2 kg = 10 FR approx 2-3 cm
> 2 kg 12 FR – 5 cm
> 2 kg = 12 FR approx 5 cm
(Or 8FR feeding tube if
Nelaton urine catheter Other: ________________________
unavailable)

Amount of sodium Neonates weight _________ x 10mL/kg


chloride 0.9% (warmed to Administer in 5-10 mL aliquots
body temperature)
Total = Maximum of 10 Other Solution/s: __________________
mL/kg Amount: ________________________

Neonatologist/Surgeon/Medical Officer signature: ________________________

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RESULT: Date: ___________________


Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________
RESULT: Date: ___________________
Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________
RESULT: Date: ___________________
Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________
RESULT: Date: ___________________
Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________
RESULT: Date: ___________________
Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________
RESULT: Date: ___________________
Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________
RESULT: Date: ___________________
Amount: __________________________________
Colour: ___________________________________ Time: ___________________
Consistency: _______________________________
Abdominal appearance pre and post procedure: Signature: ________________
Pre: ________________Post: __________________

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Attachment 4: Instaflo® troubleshooting guide

PROBLEM POSSIBLE CAUSES INTERVENTION


Leaking around catheter Poor patient positioning Position patient such that gravity
during irrigation and colonic anatomy facilitates the
Poorly inflated retention cuff flow of irrigant into the patient, (ie
supine with slightly head down
and/or slightly tilted to the left)
and the drainage of irrigant and
faeces out of the patient, (ie
supine with slight head up).

Apply gentle traction to “seat” the


retention cuff on the rectal floor.

Add additional 10ml water to


retention cuff.

Remove added water after


irrigation.
Volume of stool in rectum close to Faeces too firm Deflate intraluminal balloon and
defecatory response tripper. Upon aggressively douche to break stool
initiation of irrigation the up in the rectum.
defecatory response is triggered
resulting in the relaxation of anal Additional irrigant may have to be
sphinchters and rectal contraction infused to facilitate douching.
Reactive contraction of the Too cold or too rapid rectal Optimise rate, volume and
rectum/colon from irrigation that infusion temperature of irrigation.
is infused too rapidly, is too
voluminous, and/or is too cool.
This may or may not be associated
with patient cramping
Little or no sphincter Completely deflate retention cuff
and re-inflate with 50mL of water
(following irrigation, completely
deflate retention cuff and re-
inflate with 35mL to 40mL of
water).
Lack of faecal drainage and/or Manage small volume perianal
faecal leakage around catheter mucous or faeces leakage with
routine hygiene and absorbent
pads.
Intralumenal balloon is inflated. Deflate intralumenal balloon.
Transphincteric zone tubing is
twisted. Straighten tube and stabilise
catheter with anchor straps.

Check for anterior positioning of


triple lumen connector tubing.

Proper catheter orientation is


required to use anchor straps.
Stool is occluding catheter. Instil 300 – 500mL of lukewarm

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2019 Care
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS15/051

irrigant with intraluminal balloon


deflated and douche until
significant amounts of stool begin
to exit catheter. Additionally
irrigation may be required to clear
rectum of stool.

Check stool consistently.

More aggressive stool modification


plan/irrigation protocol or catheter
removal may be required.
Odour Stool may be accumulating in Rinse catheter more frequently.
catheter too long.
Expulsion of catheter Application of too much traction Verify no external traction is being
(tube is pulled out of patient). applied to catheter (eg
unsupported weight of collection
bag, catheter caught, fit is tension
free
(1cm or more gap between anchor
strap faceplate and anus).

Reduce the amount of traction


applied during irrigation.
Little or no sphincter tone. After rinsing catheter, reinsert (per
instructions for use) and inflate
retention cuff with 40mL of water.
Volume of stool in rectum trigger Perform rectal exam to verify no
defactory response resulting in impaction or stool is present in the
relaxation of sphincters, rectal distal rectum.
contraction and catheter
expulsion. After rinsing catheter, reinsert (per
instructions for use).

Irrigate the rectum with


intraluminal balloon deflated and
aggressively douche during
irrigation to clear rectum.

Check stool consistency.

More aggressive stool modification


plan and irrigation may be
required.

Doc Number Version Issued Review Date Area Responsible Page


CHHS15/051 1.0 December 2014 December RACC Community 30 of 31
2019 Care
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS15/051

Attachment 5: Instaflo® Product Features

Doc Number Version Issued Review Date Area Responsible Page


CHHS15/051 1.0 December 2014 December RACC Community 31 of 31
2019 Care
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register