Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [178], C).
2. 2.Show
   Draw a curtain around the patient or close the door.
   To ensure privacy and to avoid unnecessary embarrassment to the patient (NMC [178], C).
3. 3.Show
   In spinal cord injury, patients who are at risk of autonomic dysreflexia (AD) should have a blood pressure reading taken prior to the procedure. A baseline blood pressure reading should be available for comparison. For such patients where this procedure is routine and tolerance is well established, this is not required.
   In spinal cord injury, stimulus below the level of injury may result in symptoms of AD including headache and hypertension (Peate [194], C; RCN [206], C).

Procedure

1. 4.Show
   Assist the patient to lie in the left lateral position with knees flexed, the upper knee higher up the bed than the lower knee, with the buttocks towards the edge of the bed.
   This allows ease of digital insertion into the rectum, by following the natural anatomy of the colon (RCN [206], C). Flexing the knees reduces discomfort as the finger passes the anal sphincter (Peate [194], C).
2. 5.Show
   Place a disposable incontinence pad beneath the patient's hips and buttocks.
   To reduce potential infection caused by soiled linen. To avoid embarrassing the patient if faecal staining occurs during or after the procedure. E
3. 6.Show
   Wash hands with bactericidal soap and water or an alcohol‐based handrub and put on disposable apron and gloves.
   For infection prevention and control (NHS England and NHSI [161], C).
4. 7.Show
   Place some lubricating gel on a gauze square and gloved index finger.
   To minimize discomfort as lubrication reduces friction and to ease insertion of the finger into the anus and rectum. Lubrication also helps to minimize anal mucosal trauma (Peate [194], E).
5. 8.Show
   Inform the patient you are about to proceed.
   To assist with patient co‐operation with the procedure (NMC [178], C).
6. 9.Show
   In spinal cord injury patients, observe for signs of AD throughout the procedure
   In spinal cord injury, stimulus below the level of the injury may result in symptoms of AD, including hypertension (Peate [194], E; RCN [206], C).
7. 10.Show
   Observe the anal area prior to the insertion of the finger into the anus for evidence of skin soreness, excoriation, swelling, haemorrhoids or rectal prolapse.
   May indicate incontinence or pruritus. Swelling may be indicative of mass or abscess. Abnormalities such as bleeding, discharge or prolapse should be reported to medical staff before any examination is undertaken (RCN [206], C).
8. 11.Show
   Proceed to insert finger into the anus and rectum. Proceed with caution in those patients with spinal cord injury.
   The majority of spinal cord injury patients will not experience any pain (Peate [194], C).
9. 12.Show
   If the stool is type 1 (see Figure 6.3), remove one lump at a time until no more faecal matter is felt.
   To relieve patient discomfort (Peate [194], C).
10. 13.Show
    If a solid faecal mass is felt, split it and remove small pieces until no more faecal matter is felt. Avoid using a hooked finger to remove faeces.
    To relieve patient discomfort (Peate [194], C). Use of a hooked finger may cause damage to the rectal mucosa and anal sphincter (RCN [206], C).
11. 14.Show
    If faecal mass is too hard to break up or more than 4 cm across, stop the procedure and discuss with the multidisciplinary team.
    To avoid unnecessary pain and damage to the anal sphincter. The patient may require the procedure to be carried out under anaesthetic (Peate [194], C).
12. 15.Show
    As faeces are removed, they should be placed in an appropriate receiver.
    To assist in appropriate disposal and reduce the risk of contamination and cross‐infection. E
13. 16.Show
    Encourage patients who receive this procedure on a regular basis to have a period of rest or, if appropriate, to assist using the Valsalva manoeuvre.
    Patient and nurse education is required to use this technique safely. Therefore, further guidance should be sought before introducing this manoeuvre as it may lead to complications such as haemorrhoids (Peate [194], C).
14. 17.Show
    Change gloves, then wash and dry the patient's anal area and buttocks.
    To ensure the patient feels comfortable and clean. P

Post‐procedure

1. 18.Show
   Remove gloves and apron and dispose of equipment in an appropriate clinical waste bin. Wash hands.
   For prevention and control of infection (NHS England and NHSI [161], C).
2. 19.Show
   Assist the patient into a comfortable position.
   To promote comfort. P
3. 20.Show
   In spinal cord injury patients, take a blood pressure reading.
   In spinal cord injury, stimulus below the level of the injury may result in symptoms of AD, including hypertension (Peate [194], C).
4. 21.Show
   Document the findings and report them to the appropriate members of the multidisciplinary team.
   To ensure continuity of care and enable appropriate actions to be initiated (NMC [178], C; RCN [206], C).