BOWEL MANAGEMENT BOWEL MANAGEMENT FORFOR

SPINAL CORD INJURED SPINAL CORD INJURED PERSONSPERSONS

Presented by:Presented by:

Karen Flaherty, RN, ADNKaren Flaherty, RN, ADN& Michael Caplinger, RN, BSN & Michael Caplinger, RN, BSN

VABHSVABHSSCI ServiceSCI Service

West Roxbury CampusWest Roxbury Campus

OBJECTIVESOBJECTIVES

Understand normal bowel functionUnderstand normal bowel function Understand the effect of SCI on Understand the effect of SCI on

bowel functionbowel function Identify the appropriate bowel Identify the appropriate bowel

programprogram Identify complications associated Identify complications associated

with neurogenic bowelwith neurogenic bowel Identify meds associated with bowel Identify meds associated with bowel

carecare

GLOSSARYGLOSSARY

BOWEL CAREBOWEL CARE- procedure for starting/completing a - procedure for starting/completing a bowel movementbowel movement

BOWEL PROGRAM-BOWEL PROGRAM- total individualized management total individualized management plan to regularly empty the colon of stool, including diet, plan to regularly empty the colon of stool, including diet, exercise, medication, and regularly-scheduled bowel careexercise, medication, and regularly-scheduled bowel care

BTBT-bowel training-bowel training DDDD- digital dilatation- digital dilatation DIGITAL STIMULATION-DIGITAL STIMULATION- gentle movement of a gloved gentle movement of a gloved

finger in a circular pattern in the rectum to relax the finger in a circular pattern in the rectum to relax the sphincter muscle so that stool may pass during bowel sphincter muscle so that stool may pass during bowel carecare

IMPACTION-IMPACTION-stool lodged in and clogging the bowelstool lodged in and clogging the bowel INCONTINENCE-INCONTINENCE- involuntary passage of stool or urine, involuntary passage of stool or urine,

also called an accidentalso called an accident

Bowel AnatomyBowel Anatomy

NEUROGENIC BOWELNEUROGENIC BOWELWhat is It?What is It?

A medical condition caused by an injury A medical condition caused by an injury to the spinal cord that damages the to the spinal cord that damages the nervous system’s control of the colon nervous system’s control of the colon and interferes with the body’s natural and interferes with the body’s natural process for storing and eliminating solid process for storing and eliminating solid wastes. There are two patterns of wastes. There are two patterns of neurogenic bowel: neurogenic bowel: reflexicreflexic or or spasticspastic and and areflexic or flaccidareflexic or flaccid

REFLEXIC BOWELREFLEXIC BOWEL

Cervical or thoracic Level of Injury Cervical or thoracic Level of Injury (LOI)(LOI)

Injury interrupts message from colon Injury interrupts message from colon to brainto brain

Below LOI cord controls bowel Below LOI cord controls bowel reflexes (no urge to defecate)reflexes (no urge to defecate)

Stool in rectal vault triggers reflex BMStool in rectal vault triggers reflex BM Between BM’s sphincter tightBetween BM’s sphincter tight

AREFLEXIC BOWELAREFLEXIC BOWEL

SCI at lower levelSCI at lower level Reduced peristalsis Reduced peristalsis Decreased anal sphincter toneDecreased anal sphincter tone

NEUROGENIC BOWELNEUROGENIC BOWELWhat Happens?What Happens?

Unable to feel urge to defecateUnable to feel urge to defecate Unable to evacuate bowel Unable to evacuate bowel

voluntarilyvoluntarily Unable to evacuate bowel Unable to evacuate bowel

completelycompletely Ineffective peristalsisIneffective peristalsis

NEUROGENIC BOWELNEUROGENIC BOWELWhat Next?What Next?

ConstipationConstipation DiarrheaDiarrhea HemorrhoidsHemorrhoids Distention/FlatusDistention/Flatus

NEUROGENIC BOWELNEUROGENIC BOWELWhat Can Be Done?What Can Be Done?

Pt/caregiver assume responsibility Pt/caregiver assume responsibility for bowel routinefor bowel routine

Individualized bowel care program Individualized bowel care program established during rehabestablished during rehab

LOI, scheduling needs, position, LOI, scheduling needs, position, comfort, discharge goal comfort, discharge goal

Goal: Effective, efficient evacuationGoal: Effective, efficient evacuation

Bowel ProgramBowel Program in Spinal Cord Injury in Spinal Cord Injury

With loss of sensation & motor With loss of sensation & motor control normal control over bowel control normal control over bowel activity is no longer possible activity is no longer possible

Spinal cord injured person must Spinal cord injured person must establish a bowel programestablish a bowel program

Type of neuron injury should be Type of neuron injury should be taken into account.taken into account.

Benefits of a Bowel Benefits of a Bowel ProgramProgram

Prevents accidents/incontinencePrevents accidents/incontinence Prevents diarrhea, constipation & Prevents diarrhea, constipation &

impactionimpaction Increases independenceIncreases independence Decreases depression & feelings of Decreases depression & feelings of

helplessnesshelplessness Reduces workload of personal care Reduces workload of personal care

attendantattendant

REFLEXIC BOWEL REFLEXIC BOWEL PROGRAMPROGRAM

Laxative meds Laxative meds Digital stimulationDigital stimulation Gastrocolic reflexGastrocolic reflex Q every other dayQ every other day

or Three Times or Three Times per Weekper Week

DisimpactDisimpact Insert suppositoryInsert suppository Digital stimulationDigital stimulation Evacuation Evacuation

completecomplete CleanupCleanup

AREFLEXIC BOWEL AREFLEXIC BOWEL PROGRAMPROGRAM

Use gravityUse gravity Digital stimulationDigital stimulation Daily or moreDaily or more Strain, abd muscle contraction, bend, Strain, abd muscle contraction, bend,

liftlift Complete when rectal vault emptyComplete when rectal vault empty CleanupCleanup

Factors that Affect the Factors that Affect the Success of a Bowel Success of a Bowel

ProgramProgram

Previous bowel Previous bowel historyhistory

TimingTiming Privacy & comfortPrivacy & comfort Emotional stressEmotional stress Fluids/Food Fluids/Food Activity level Activity level

MedicationsMedications IllnessIllness PositioningPositioning External massageExternal massage Valsalva Valsalva Assistive/Adaptive Assistive/Adaptive

devicesdevices

Common MedicationsCommon Medications

Laxatives Laxatives stimulant, stimulant, osmotic, bulkosmotic, bulk

Stool SoftenersStool Softeners SuppositoriesSuppositories

BOWEL MEDICATIONSBOWEL MEDICATIONS

Stimulant LaxativesStimulant Laxatives-increase -increase peristalsis, increase transit time, keep peristalsis, increase transit time, keep stool soft stool soft

Osmotic LaxativesOsmotic Laxatives-pull water into -pull water into colon to increase stool bulkcolon to increase stool bulk

Bulk LaxativesBulk Laxatives-add bulk to stool-add bulk to stool Stool SoftenersStool Softeners-retain fluid in stool, -retain fluid in stool,

keep softkeep soft SuppositoriesSuppositories-increase peristalsis-increase peristalsis

Common Bowel Problems Common Bowel Problems and Solutionsand Solutions

CONSTIPATION:CONSTIPATION: -less than normal amts of stool-less than normal amts of stool -hard, small or very large bulky-hard, small or very large bulky -poor results for 2 bowel routines-poor results for 2 bowel routines -poor appetite, nausea, abd distention-poor appetite, nausea, abd distention CauseCause:poor fluid/fiber/food intake, not :poor fluid/fiber/food intake, not

following program, decreased activity, following program, decreased activity, medications medications

CONSTIPATION CONSTIPATION SOLUTIONSSOLUTIONS

Dig stim/disimpact, then bowel Dig stim/disimpact, then bowel care programcare program

No stool, DD, oral laxative then No stool, DD, oral laxative then bowel program 6-12 hours laterbowel program 6-12 hours later

Increase frequency of bowel care Increase frequency of bowel care until regulateduntil regulated

Increase fluids and activityIncrease fluids and activity Maintain regular bowel programMaintain regular bowel program

Common Bowel ProblemsCommon Bowel Problemsand Solutionsand Solutions

DIARRHEA:DIARRHEA: loose, watery stools, usually 3 or loose, watery stools, usually 3 or

more times per daymore times per day urine may become concentrated, urine may become concentrated,

mucous membranes drymucous membranes dry Cause:Cause: dietary, caffeine, overuse dietary, caffeine, overuse

of laxatives, stress, antibioticsof laxatives, stress, antibiotics

DIARRHEA SOLUTIONSDIARRHEA SOLUTIONS

Avoid irritant foodsAvoid irritant foods Use BRAT foodsUse BRAT foods Hydrate to replete lossesHydrate to replete losses Consider yogurt/lactobacillus while Consider yogurt/lactobacillus while

on antibioticson antibiotics R/O constipation/impactionR/O constipation/impaction

Common Bowel Problems Common Bowel Problems and Solutionsand Solutions

HEMORRHOIDS:HEMORRHOIDS: bulging around anusbulging around anus may cause bleeding with defecationmay cause bleeding with defecation may trigger AD with LOI T6 or above may trigger AD with LOI T6 or above Cause:Cause: hard stools, straining, hard stools, straining,

vigorous digital stimulationvigorous digital stimulation

HEMORRHOID SOLUTIONSHEMORRHOID SOLUTIONS

Avoid constipationAvoid constipation Hemorrhoid creams/suppositoriesHemorrhoid creams/suppositories Minimize DDMinimize DD Increase stool softenerIncrease stool softener Increase use of lubeIncrease use of lube Limit strain/time over toiletLimit strain/time over toilet

Common Bowel Problems Common Bowel Problems and Solutionsand Solutions

ABDOMINAL ABDOMINAL DISTENTION/FLATUSDISTENTION/FLATUS

swallowing air while swallowing air while eating/drinkingeating/drinking

causative food/fluidscausative food/fluids delayed gastric emptyingdelayed gastric emptying

DISTENTION/FLATUS DISTENTION/FLATUS SOLUTIONSSOLUTIONS

Eat food slowlyEat food slowly Avoid gulpingAvoid gulping Avoid food/fluid known to cause Avoid food/fluid known to cause

increased GI gasincreased GI gas Maintain regular bowel care Maintain regular bowel care

regimeregime Avoid constipationAvoid constipation

GAS CAUSING GAS CAUSING FOOD/FLUIDSFOOD/FLUIDS

BeansBeans BroccoliBroccoli CornCorn CucumbersCucumbers PeppersPeppers OnionsOnions TurnipsTurnips PeasPeas

Carbonated Carbonated beveragesbeverages

Caffeinated Caffeinated beveragesbeverages

ApplesApples AvocadosAvocados CantaloupeCantaloupe MelonsMelons

ColostomyColostomy Colostomy: a surgical construction of an

artificial anus between the colon and the surface of the abdomen.

Indications: cancer, diverticulitis, imperforate anus, trauma, and a treatment for bowel dysfunction for spinal cord injured persons.

KEY POINTS KEY POINTS

Effective/efficient bowel program Effective/efficient bowel program promotes independence and promotes independence and improves quality of lifeimproves quality of life

Prevents incontinencePrevents incontinence Provides control over body functionProvides control over body function Prevents healthcare problemsPrevents healthcare problems

The End The End