SCI Neurogenic Bowel Care: Nursing Guidelines

Assessment

To determine the most effective bowel care routine for a person with spinal cord impairment (SCI), the health care provider will:

Obtain a bowel care history.
Consider neurological level of impairment to anticipate the impact on bowel care routine.
Assess effectiveness of current bowel function/program.
Assess current bowel care routine (e.g., frequency, time of day/evening, length of routine).
Consider medications/herbals, diet, and fluids.
Determine the patient/caregiver's knowledge, readiness to learn, and ability to perform the procedure.
Consider problems associated with bowel care routine (e.g., digital stimulation, positioning, autonomic dysreflexia, hemorrhoids, rectal prolapse).
Assess for spinal shock, which prevents reflexive responses.

Upper Motor Neuron (Reflexic) and Lower Motor Neuron (Areflexic) Impairment

Reflexic bowel due to upper motor neuron (UMN) impairment: Defecation cannot be triggered by conscious effort. The spinal cord and colon innervations remain intact, allowing for reflex coordination and stool propulsion. Reflex pathways usually continue to function below the lesion and can be utilized to stimulate defecation. The goal of bowel care for a patient with UMN bowel is to keep the stool soft yet firm, evacuate it on a routine basis at least three times a week, and prevent embarrassing accidents.
Areflexic bowel due to lower motor neuron (LMN) impairment: Spinal cord mediated reflex defecation does not occur, due to complete or incomplete damage at or below T12. It results from partial or complete destruction of the sacral reflex arc at S2-4. Individuals with LMN bowel dysfunction may not respond to usual bowel interventions such as digital stimulation because the spinal reflex arc is diminished or absent. The goal of bowel care for a patient with LMN function is to keep the stool well formed, the rectal vault clear, and prevent embarrassing accidents.

Points to Consider

Bowel care may require using two methods of rectal stimulation: mechanical and chemical. These can be used individually or in combination.
Rectal stimulation may cause autonomic dysreflexia (AD) in individuals with cervical or high thoracic spinal cord lesions (T6 or above). If this occurs, consider using a topical anesthetic gel or ointment to decrease this risk.
Diet plays a large part in a successful bowel routine. Certain foods may make the stool hard, soft, l oose, or produce flatulence. Consult diet manual or dietitian, if indicated.
Individuals with chronic constipation, should be maintained on a well balanced diet, be adequately hydrated, have appropriate daily physical activity, and use oral medications, if necessary.
Due to sensory loss, use of bedpans should be strictly prohibited as it puts the person at significant risk for skin breakdown. If bowel care on a commode or toilet is not possible, place the patient on his/her side with appropriate padding under his/her buttocks for bowel care.

Table 1. Bowel Care Guidelines

Interventions	Reflexic Bowel (UMN)	Areflexic Bowel (LMN)
Positioning	Upright on commode if possible.	Upright on commode if possible.
Diet	High in fiber as tolerated	High in fiber as tolerated
Fluid	2-3 liters/day as tolerated	2-3 liters/day as tolerated
Stool consistency	Soft, formed	Firm, but not hard
Time of routine	30-60 minutes after meals using the gastrocolic reflex	30-60 minutes after meals using the gastrocolic reflex
Frequency	Daily until routine established without breakthrough accidents, then every other day or every third day as tolerated. A program greater than every 3 days may lead to hard stools and constipation	Daily
Medications - oral	Stool softener, bulk agent, stimulant, as prescribed	Stool softener, bulk agent, stimulant, as prescribed
Medications - rectal	Chemical agent (e.g., suppository) to move stool into the rectum for evacuation; Suppositories work by stimulating peristalsis. Manually remove stool in rectal vault prior to inserting suppository and assure that the suppository is in contact with the rectal wall.	Chemical agent (e.g., suppository) is not routinely used for areflexic bowel program.
Digital stimulation	Yes: Used pre- and post-manual removal of stool to stimulate defecation reflex.	No: Digital stimulation is ineffective. Manual evacuation of stool in rectum as needed only.
Other techniques	Abdominal massage, weight shifts and different positions, abdominal binder, or consuming hot drink prior to bowel care.	Valsalva, abdominal massage, weight shifts and different positions, abdominal binder, or consuming hot drink prior to bowel care.

Table 2. Troubleshooting Bowel Care Problems

Problem	Possible Cause	Intervention
Bowel Accidents	Ineffective bowel routine	Evaluate oral medications, request changes prn Modify intake, diet, fluid intake and time of routine. Evaluate stool consistency, change as necessary. Make minimal changes at any one time to determine the actual cause of accident. Avoid more than one change in routine per week.
Constipation	Diet, insufficient fluid intake, insufficient fiber Not doing prescribed bowel regimen Medications (e.g., anticholinergics, opiates or narcotic analgesics)	Modify diet and fluid intake as needed Increase fiber and increase fluid intake Adhere to bowel regimen Increase activity Consult with physician about pain control options
Hemorrhoids	Stool too hard Too vigorous digital stimulation	Increase stool softener Modify diet and increase fiber Use gentle digital stimulation
Excessive Flatulence	Air in abdomen Diet: Increased or rapid intake of fiber or reaction to certain foods	Chew with mouth closed Avoid drinking with straw to prevent swallowing air Modify diet Use products such as Beano^TM or medicinal charcoal tablets Increase frequency of bowel program if tolerated
Diarrhea	Too much stool softener Diet Impaction Presence of intestinal infection	Decrease stool softener Modify diet: Decrease fiber or eliminate trigger foods Confirm impaction (e.g., abdominal x-ray), then perform thorough manual removal. Obtain order to screen for infection (Clostridium difficile).
Autonomic dysreflexia	Presence of stool in rectum, impaction Hypersensitive to any stimulation below level of impairment	Perform manual removal of stool using a topical anesthetic ointment or gel. Modify bowel routine, as needed.

Administrative and financial support provided by the Paralyzed Veterans of America