| Bowel care after spinal injury | | | Bowel care on discharge from a specialised spinal injury unit has far reaching implications for the quality of life for patients recovering from spinal injury. “Management of the bowels is undoubtedly the most distressing aspect of paraplegia, especially to the newly injured.” However, because of limited alternatives, the methods of management have not changed significantly over the years.’ “A spinal cord injury is a traumatic event producing a multitude of unanticipated irreversible physical changes that immediately block a person’s capabilities of meeting individual life demands. A study by Glickman and Kamm’ found that once a person adapted to their paralysis, one of their major complaints or concerns was bowel dysfunction. Another study by Levi et al’ revealed that almost 41% of persons rated bowel dysfunction as a moderate to severe life-limiting problem. “Fear of bowel accidents is a commonly stated reason why people with spinal cord injuries (SCI) do not engage in activities outside the home or travel away from home, and so the impact of poor bowel management actually extends far beyond impaired intestinal motility.
| | Neurogenic Bowel |
“Neurogenic bowel’ is a term that relates colon dysfunction (such as constipation, incontinence and discoordination of defaecation) to lack of nervous control. The nerve supply to the large intestine is generated from three elements:
· an intrinsic component located entirely within the bowel
· autonomic nervous stimulation – both sympathetic and parasympathetic nervous systems
· an element of central nervous system innervation to control the actual act of defaecation.
A spinal cord injury may result in two different types of neurogenic bowel, depending on the level at which the injury occurred – upper or lower neurone damage. The lower motor neurone (LMN) colon (below T12) tends to be ‘relaxed and flaccid; and no spinal cord-mediated reflex peristalsis occurs. Slow stool propulsion with segmental colonic peristalisi is coordinated by the myenteric plexus alone while water absorption continues. The external anal sphincter is denervated, increasing the risk of incontinence. Although peristalsis will return, these movements are quite ineffective without the support of the spinal reflex. Upper motor neurone (UMN) bowel results from a spinal cord lesion above the conus medullaris, where the colon has been described as being spastic due to the excessive colonic wall and anal tone observed. Reflex activity is maintained and the bowel will contract and empty when stimulated. Anal sphincter tone is maintained.
| | The bowel programme |
“A bowel programme is a comprehensive individualised treatment plan focused on preventing incontinence, achieving effective and efficient colonic evacuation, and preventing the complications of neurogenic bowel dysfunction. Devising a reliable bowel programme involves understanding the significance of a pre-injury pattern of bowel habits, the current nutritional status and the type of neurogenic bowel dysfunction exhibited, together with knowledge and appropriate skill to stimulate defaecation. Bowel care is the individually developed and prescribed procedure carried out by the patient, nurse, or trained attendant to periodically evacuate stool from the colon. The National Rehabilitation Hospital SCI team discourage family members from performing such intimate and emotionally charged tasks, which may have negative effects on family relationships. Time well spent during active rehabilitation and early community re-entry in the pursuit of a long-term bowel management strategy can be used to prevent both short and long-term sequelae of neurogenic bowel dysfunction. People with paraplegia will usually be totally independent in all aspects of bowel care. With good upper limb function they would be able to perform toilet transfers, insert suppositories and cerry out manual evacuation of stool. In the absence of good manual dexterity and with weak upper limbs, the person with an UMN lesion will achieve reflex emptying but will need a carer to carry out digital stimulation and manual evacuation. It must be recognised that this is a duty of care to the individual with SCI and consent must be obtained, which may be verbal, written or implied. The person with an LMN lesion will usually be required to persist largely with manual evacuation.
| | Facilitated defaecation |
After SCI the goal is to re-achieve as normal and efficient a defaecation task as possible. The goals of bowel care are to facilitate controllable defaecation of the maximal stool volume in the least amount of time, with avoidance of stool incontinence there after. People with a LMN injury often have more difficulty with their bowel care because of the absence of spinal reflex peristalsis (areflexic bowel) and external anal sphincter tone. LMN bowel care procedure usually consists of removing stool with the finger and may include digital stimulation to enhance local segmental peristalsis. Manual evacuation is repeated with digital stimulation until there is no further palpable stool. The absence of palpable stool and/or tightening of the internal anal sphincter signals the end of bowel care. People with UMN injury need to anticipate the urge to defaecate with a scheduled trigger every one to three days. This is achieved by stimulating the reflex manually with a finger inserted into the rectumdigital stimulation. Digital stimulation is a technique used to induce reflex peristaltic wave from the colon to evacuate stool. The initial trigger for defaecation is usually a suppository, enema or mini-enema. The chemical stimulant must be placed directly against the mucosa of the upper rectum, therefore the rectum must be manually checked and cleaned of faeces (if required) prior to administration. A waiting period follows, as the active ingredient dispenses and stimulates stool flow, and is augmented as necessary with digital stimulations, which should be repeated every 10 minutes to maintain progress with defaecation.
| | Autonomic Dysreflexia |
Chronic constipation may give rise to autonomic dysreflexia. This is a potentially life-threatening condition and can be caused by constipation in people with SCI who are injuryed above T6. autonomic disreflexia results in a sudden increase in blood pressure characterised by any of the following symptoms: profuse sweating; blotching of the skin; goose pimples; a severe, pounding headache. Dysreflexia should resolve when the cause is removed – evacuation of an impacted bowel. Some patients will require nifedipine and xylocaine gel prior to the evacuation procedure in order to prevent this complication. The neurogenic colon remains a bans in the existence of people with SCI and rehabilitation interventions have changed littie over the past 50 years. Manual evacuation and digital stimulation are well established components of an effective and efficient bowel programme. These procedures, although well practised by nurses and care attendants in specialised spinal injury units, are not well established oraroutine procedures in general hospitals but should be more familiar to nurses working in the community or in residential homes. In order to maintain an appropriate level of care for these patients, it is necessary to ensure the continuation of patients essential bowel programmes following discharge from the specialised spinal injury units.
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