British Journal of Nursing - Rationale and procedure for performing digital removal of faeces

In a healthy person, normal stool output is estimated at approximately 150 g to 200 g per day (Royal College of Nursing (RCN), 2012). Bowel frequency ranges between three times a day and three times a week (RCN, 2012). Stool consistency can vary depending on gender, health and diet (for stool classification see the Bristol Stool Form Scale) (Norgine Pharmaceuticals, 2000; RCN, 2012). The process for rectal emptying is a voluntary action. Faeces move into the rectum, which causes rectal distension and evokes the desire to defecate—this term is known as the ‘call to stool’ (RCN, 2012).

Normal bowel movements

Under normal circumstances, an individual adopts a sitting or squatting position allowing for straightening of the anorectal angle and the relaxation of the external anal sphincter and puborectalis muscle. There is a rise in abdominal pressure and the muscles of the anterior abdominal wall become tense to direct pressure down into the pelvis (RCN, 2012). Stool enters the lower rectum, which initiates a spontaneous recto-sigmoid contraction, and is pushed through the anal canal (RCN, 2012).

This sequence of events is repeated until the rectum is empty and the person no longer has an urge to defecate (RCN, 2012). Once defecation is complete, the closing reflex of the external sphincter is stimulated, which ensures continence is maintained (RCN, 2012).

Patient assessment

Nurses need to be aware of interventions that can improve and maintain the patient's normal bowel function or to investigate a patient's concerns about constipation or problems with defecation. These include lifestyle advice on, for example, weight management, fluids and diet, smoking cessation and exercise. As part of a holistic assessment, nurses should give patients dietary advice to promote the ideal stool consistency, as well as general health. An assessment should include:

Discussing the patient's existing diet and any therapeutic diets they have tried (and whether their nutritional intake is balanced) (RCN, 2012)

Recommending patients use a food and fluid diary to record intake and help establish a baseline. According to the British Dietetic Association (2017), a healthy adult should drink between 1.5 litres and 2.5 litres a day

Assessing the patient's urine for colour and consistency to ensure that they are adequately hydrated (Coggrave, 2007)

Suggesting the patient modifies their diet one food at a time to eradicate contributory factors

Considering screening for malnutrition and risk factors for malnutrition

Taking into account the patient's religious and cultural beliefs

Considering onward referral to a dietitian if required.

Digital removal of faeces

The digital (manual) removal of faeces is defined as an invasive procedure that involves the manual removal of faeces from the rectum using a gloved finger (Dougherty and Lister, 2015). This should only be performed following a complete bowel assessment to understand the patient's normal bowel habits (National Institute for Health and Care Excellence (NICE), 2017), bowel history including constipation, complications, current medication and medical history.

Digital removal of faeces should only be performed following a complete bowel assessment and for the following indications:

Faecal impaction/loading

Incomplete defecation

An inability to defecate

When other methods of bowel emptying have failed, or are deemed inappropriate

If a patient has a neurogenic bowel dysfunction

For patients with a spinal cord injury.

During the procedure, the nurse should observe the patient at all times for signs of distress, which could include pain or discomfort, bleeding, symptoms of autonomic dysreflexia or collapse (RCN, 2012; Dougherty and Lister, 2015). Nurses should not perform digital removal of faeces if the patient has recently undergone rectal surgery or if there is any indication of trauma to the anal or rectal area (Peate, 2016).

Patients who may require the digital removal of faeces

Digital removal of faeces is often carried out for patients with spinal injuries, spina bifida and multiple sclerosis as part of their routine bowel management (Dougherty and Lister, 2015) in conjunction with a fibre-rich diet, digital stimulation, suppositories, enemas, abdominal massage and stool softeners. Digital stimulation is a method of initiating the defecation reflex by dilating the anus either using a finger or an anal dilator. It is important to note that this procedure is useful only if the rectum is full (Dougherty and Lister, 2015). Advances in oral medications and rectal and surgical treatments have reduced the need for the digital removal of faeces in patients (Dougherty and Lister, 2015).

Digital removal of faeces should be performed only by a nurse deemed competent, with the correct knowledge, skills and ability required for safe practice (Nursing and Midwifery Council, 2018). Competent nurses should have successfully completed bowel-dysfunction training, which includes the practical and theoretical aspects of digital removal of faeces, and follow local protocols and policies.

Autonomic dysreflexia

Autonomic dysreflexia is an abnormal response from the autonomic nervous system to a painful stimulus unique to patients with a spinal cord injury at the sixth thoracic vertebrae or above (RCN, 2012). A distended bowel caused by constipation can lead to autonomic dysreflexia.

Nurses should be aware that acute autonomic dysreflexia can be a response to digital interventions and must assess for the signs and symptoms throughout the procedure. These include headache, hypertension, brachycardia, sweating, flushes, nasal obstruction, pallor below the level of spinal injury and hypertension (RCN, 2012; Dougherty and Lister, 2015). Severe hypertension may lead to life-threatening complications such as intracranial bleeding, seizure or retinal detachment. Note that the most significant symptom is the rapid onset of a severe headache. If this occurs the invention should be stopped immediately and the patient monitored until symptoms desist (Dougherty and Lister, 2015).

The digital removal of faeces can be a distressing, painful and dangerous procedure. Nurses must ensure that they follow best practice guidelines and local policies when performing this role. Caution should be taken to avoid damage to the vagus nerve in the rectal wall as this can slow the patient's heart rate. Take care to minimise the risk of bowel perforation, bleeding or rectal trauma (Dougherty and Lister, 2015). The equipment required to perform digital removal of faeces is listed in Box 1. The digital faecal removal procedure is given in Box 2.

Box 1.

Equipment

Disposable apron and two pairs of gloves

Lubricating gel

Swabs

Commode or bedpan

Specimen pot (if required)

Local anaesthetic gel (if prescribed)

Disposable incontinence pad

Clinical waste bag

Box 2.

Digital removal of faeces: step-by-step procedure

Confirm the patient's identity, and explain and discuss the full procedure

Obtain consent either verbal, written or implied. Ask the patient if they would like to have a chaperone present. The procedure must be stopped at any time if the patient requests this. If the patient lacks capacity, practitioners must act in accordance with the Mental Capacity Act 2005

Assess the patient's specific requirements and the reason for intervention. If the patient is constipated a full physical, psychological and social assessment should be completed

Check for any allergies such as latex

Wash hands and put on an apron and one pair of non-latex gloves. This is to ensure that hygiene and infection control measures are maintained

Close the door or draw the curtains to maintain privacy and dignity

Record the patient's pulse rate before and during the procedure if this is used as an acute intervention

Record the patients' blood pressure before and during the procedure if the patient has a spinal cord injury. A baseline blood pressure should be recorded for comparison. For patients where this procedure is part of a well-established bowel routine, this is not required

Encourage the patient to empty their bladder first. A full bladder can create discomfort during the procedure

Place the waterproof pad underneath the patient

Remove the patient's clothing from the waist down if they are unable to do this themselves

The patient should lie on their left side, knees flexed, with the upper knee higher than the lower knee and buttocks near the edge of the bed. This supports the easy passage of the finger into the rectum. Note that patients with musculoskeletal conditions may not be able to lie in this position. Ensure you have adequate lighting and that the patient is not at risk of falling from the bed

Observe the anal area for evidence of skin soreness, swelling, excoriation, haemorrhoids, anal skin tags, infestation, foreign bodies or a rectal prolapse. Swelling may be indicative of a mass or abscess. Report any abnormalities such as bleeding, discharge or prolapse and do not continue the procedure but seek additional advice

If the patient has a spinal injury, observe for signs of autonomic dysreflexia throughout the procedure

Put on an additional pair of gloves

Place lubricating gel on a gloved finger

Inform the patient that the procedure is about to begin

Proceed with caution. Gently insert the lubricated finger into the anus and slowly advance into the rectum

For digital rectal stimulation insert the lubricated gloved finger into the anus and slowly rotate the finger in circular movements. Contact should be maintained with the rectal mucosa. Gently stretch the anal canal, this helps the sphincter to relax and the rectum contract

Check the stool type. If it is type 1 on the Bristol Stool Form Scale, remove one lump at a time until no more faecal matter can be felt. This will relieve patient discomfort. If the stool is soft gently circle the finger continuously to remove faeces

If the matter is solid, use the index finger to split it and remove individual pieces at a time, taking care not to cause rectal trauma. Avoid using a hooked finger to remove faeces, this may cause damage to the rectal mucosa and anal sphincter. Using a hooked finger can cause scratching or scoring of the mucosa

During the procedure carry out abdominal massage

If the faecal matter is more than 4 cm across and is too hard and solid to break up, discontinue the procedure to avoid any pain or damage to the anal sphincter and discuss other approaches with the multidisciplinary team. It may be necessary for the procedure to be carried out under anasthetic

Place the faeces in an appropriate receiver for disposal as it is removed to reduce the likelihood of contamination and cross-infection

Allow the patient to rest if needed. If appropriate, ask the patient to breathe in and force air out of the mouth with the nose closed. This is the Valsalva manoeuvre and can assist with the passage of faeces into the rectum

Observe the patient throughout for any signs of distress and stop if the patient complains of pain or asks you to stop. If there are any signs of autonomic dysreflexia discontinue immediately. It may be necessary to refer spinal injury patients to the local spinal unit

Once the rectum is empty, carry out a final digital check after 5 minutes to ensure evacuation is complete

Remove top layer of gloves. Wash and dry the buttocks and anal area

Remove gloves and apron and dispose of appropriately in clinical waste. Wash hands

Assist the patient to a comfortable position

For spinal injury patients, record blood pressure

Document colour, consistency and amount using the Bristol scale

Document any abnormalities and report any findings to the multidisciplinary team if necessary

Source: Norgine Pharmaceuticals, 2000; Pegram et al, 2008; Royal College of Nursing, 2012; Dougherty and Lister, 2015; Peate, 2015; National Institute for Health and Care Excellence, 2017; Pokorny, 2017; Nursing and Midwifery Council; 2018

Conclusion

Bowel management is an important aspect of holistic care and failure to provide this can be fatal for some patients. Performing digital removal of faeces can be an uncomfortable and embarrassing procedure for patients and must only be carried out by a competent practitioner who has completed a risk assessment. Alternative assistance with defecation such as laxatives and digital rectal stimulation should be considered for long-term management.

LEARNING POINTS

Know how to undertake a bowel assessment in adults

Have greater knowledge of the procedure for digital removal of faeces

Understand the importance of monitoring care in patients who are unable to defecate

Understand the complications that may arise during digital removal of faeces