Chapter 6: Elimination
Skip chapter table of contents and go to main content
Digital removal of faeces
Definition
Digital removal of faeces (DRF) is an invasive procedure involving the removal of faeces from the rectum using a gloved finger. This should only be performed when necessary and after individual assessment (RCN [206]).
Related theory
Managing bowel problems such as constipation and prolonged bowel evacuation in patients following spinal cord injury requires a multimodality approach. This includes dietary fibre, digital stimulation, enemas, suppositories, stool softeners and abdominal massage (Peate [194]).
Autonomic dysreflexia (AD) is unique to patients with spinal cord injury at the sixth thoracic vertebra or above. It is an abnormal response from the autonomic nervous system to a painful (noxious) stimulus below the level of the spinal cord injury (RCN [206]). The signs and symptoms of AD are headache, flushing, sweating, nasal obstruction, blotchiness above the lesion and hypertension, the most significant being the rapid onset of a servere headache. Distended bowel caused by constipation or impaction can lead to AD and therefore it is important that an effective programme of bowel management is established and followed (Eldahan and Rabchevsky [73]). Acute AD may occur in response to digital intervention. It is therefore important that all healthcare professionals who carry out digital interventions on individuals with spinal cord injury are aware of the signs and symptoms; should any occur, the intervention must be stopped immediately (RCN [206]).
Evidence‐based approaches
Rationale
Advances in orally and rectally administered medicines as well as surgical treatments have reduced the need for DRF to be performed; however, for certain groups of patients, such as those with spinal injuries, spina bifida or multiple sclerosis, this procedure may be the only suitable bowel‐emptying technique, forming a long‐standing, integral part of their bowel routine (RCN [206]).
DRF can be distressing, painful and dangerous. In particular, stimulation of the vagus nerve in the rectal wall can slow the patient's heart, and there is a risk of bowel perforation and bleeding (Peate [194]).
Indications
Indications for assisted evacuation of bowels (DRF or digital stimulation) include:
- faecal impaction/loading
- incomplete defaecation
- inability to defaecate
- failure or unsuitability of other bowel‐emptying techniques
- neurogenic bowel dysfunction
- spinal cord injury (RCN [206]).
Patients are at risk of rectal trauma if these procedures are not performed with care or knowledge. The nurse should be aware of any conditions that may contraindicate performance of these procedures (see ‘Precautions’ in the section on digital rectal examination above).
Clinical governance
DRF should be performed by registered nurses who demonstrate competency in this procedure, possessing the knowledge, skills and abilities required for lawful, safe and effective practice (RCN [206]). In addition, they should ensure that their employer has defined policies and procedures for undertaking this role (RCN [206]). If appropriate, the patient and their personal carer may wish for the carer to maintain the established programme of bowel management once the patient has left hospital (Peate [194]).
Pre‐procedural considerations
Specific patient preparations
If this procedure is used as an acute intervention, the patient's pulse rate should be recorded before and during the process. Patients with a spinal cord injury should also have their blood pressure measured before, during and after the procedure. A baseline blood pressure measurement should be available for comparison (RCN [206]). Every time the procedure is performed, the consistency of the stool should be noted before continuing. If the stool is hard and dry, lubricant suppositories should be inserted and left for 30 minutes before commencing. If the stool is too soft to remove effectively, consider delaying the procedure for 24 hours to allow further water reabsorption to occur.
During the procedure, the nurse should observe the patient for signs of:
Procedure guideline 6.24
