BOWEL MANAGEMENT FOR SPINAL CORD INJURED PERSONS Presented by: Karen Flaherty, RN, ADN & Michael Caplinger, RN, BSN VABHS SCI Service West Roxbury Campus

OBJECTIVES n Understand normal bowel function n Understand the effect of SCI on bowel function n Identify the appropriate bowel program n Identify complications associated with neurogenic bowel n Identify meds associated with bowel care

GLOSSARY n BOWEL CARE- procedure for starting/completing a bowel movement n BOWEL PROGRAM- total individualized management plan to regularly empty the colon of stool, including diet, exercise, medication, and regularly-scheduled bowel care n BT-bowel training n DD- digital dilatation n DIGITAL STIMULATION- gentle movement of a gloved finger in a circular pattern in the rectum to relax the sphincter muscle so that stool may pass during bowel care n IMPACTION-stool lodged in and clogging the bowel n INCONTINENCE- involuntary passage of stool or urine, also called an accident

Bowel Anatomy

NEUROGENIC BOWEL What is It? A medical condition caused by an injury to the spinal cord that damages the nervous system’s control of the colon and interferes with the body’s natural process for storing and eliminating solid wastes. There are two patterns of neurogenic bowel: reflexic or spastic and areflexic or flaccid A medical condition caused by an injury to the spinal cord that damages the nervous system’s control of the colon and interferes with the body’s natural process for storing and eliminating solid wastes. There are two patterns of neurogenic bowel: reflexic or spastic and areflexic or flaccid

REFLEXIC BOWEL n Cervical or thoracic Level of Injury (LOI) n Injury interrupts message from colon to brain n Below LOI cord controls bowel reflexes (no urge to defecate) n Stool in rectal vault triggers reflex BM n Between BM’s sphincter tight

AREFLEXIC BOWEL n SCI at lower level n Reduced peristalsis n Decreased anal sphincter tone

NEUROGENIC BOWEL What Happens? n Unable to feel urge to defecate n Unable to evacuate bowel voluntarily n Unable to evacuate bowel completely n Ineffective peristalsis

NEUROGENIC BOWEL What Next? n Constipation n Diarrhea n Hemorrhoids n Distention/Flatus

NEUROGENIC BOWEL What Can Be Done? n Pt/caregiver assume responsibility for bowel routine n Individualized bowel care program established during rehab n LOI, scheduling needs, position, comfort, discharge goal n Goal: Effective, efficient evacuation

Bowel Program in Spinal Cord Injury n With loss of sensation & motor control normal control over bowel activity is no longer possible n Spinal cord injured person must establish a bowel program n Type of neuron injury should be taken into account.

Benefits of a Bowel Program n Prevents accidents/incontinence n Prevents diarrhea, constipation & impaction n Increases independence n Decreases depression & feelings of helplessness n Reduces workload of personal care attendant

REFLEXIC BOWEL PROGRAM n Laxative meds n Digital stimulation n Gastrocolic reflex n Q every other day or Three Times per Week or Three Times per Week n Disimpact n Insert suppository n Digital stimulation n Evacuation complete n Cleanup

AREFLEXIC BOWEL PROGRAM n Use gravity n Digital stimulation n Daily or more n Strain, abd muscle contraction, bend, lift n Complete when rectal vault empty n Cleanup

Factors that Affect the Success of a Bowel Program n Previous bowel history n Timing n Privacy & comfort n Emotional stress n Fluids/Food n Activity level n Medications n Illness n Positioning n External massage n Valsalva n Assistive/Adaptive devices

Common Medications n Laxatives stimulant, osmotic, bulk n Stool Softeners n Suppositories

BOWEL MEDICATIONS n Stimulant Laxatives-increase peristalsis, increase transit time, keep stool soft n Osmotic Laxatives-pull water into colon to increase stool bulk n Bulk Laxatives-add bulk to stool n Stool Softeners-retain fluid in stool, keep soft n Suppositories-increase peristalsis

Common Bowel Problems and Solutions n CONSTIPATION: n -less than normal amts of stool n -hard, small or very large bulky n -poor results for 2 bowel routines n -poor appetite, nausea, abd distention n Cause:poor fluid/fiber/food intake, not following program, decreased activity, medications

CONSTIPATION SOLUTIONS n Dig stim/disimpact, then bowel care program n No stool, DD, oral laxative then bowel program 6-12 hours later n Increase frequency of bowel care until regulated n Increase fluids and activity n Maintain regular bowel program

Common Bowel Problems and Solutions n DIARRHEA: n loose, watery stools, usually 3 or more times per day n urine may become concentrated, mucous membranes dry n Cause: dietary, caffeine, overuse of laxatives, stress, antibiotics

DIARRHEA SOLUTIONS n Avoid irritant foods n Use BRAT foods n Hydrate to replete losses n Consider yogurt/lactobacillus while on antibiotics n R/O constipation/impaction

Common Bowel Problems and Solutions n HEMORRHOIDS: n bulging around anus n may cause bleeding with defecation n may trigger AD with LOI T6 or above n Cause: hard stools, straining, vigorous digital stimulation

HEMORRHOID SOLUTIONS n Avoid constipation n Hemorrhoid creams/suppositories n Minimize DD n Increase stool softener n Increase use of lube n Limit strain/time over toilet

Common Bowel Problems and Solutions n ABDOMINAL DISTENTION/FLATUS n swallowing air while eating/drinking n causative food/fluids n delayed gastric emptying

DISTENTION/FLATUS SOLUTIONS n Eat food slowly n Avoid gulping n Avoid food/fluid known to cause increased GI gas n Maintain regular bowel care regime n Avoid constipation

GAS CAUSING FOOD/FLUIDS n Beans n Broccoli n Corn n Cucumbers n Peppers n Onions n Turnips n Peas n Carbonated beverages n Caffeinated beverages n Apples n Avocados n Cantaloupe n Melons

Colostomy n n Colostomy: a surgical construction of an artificial anus between the colon and the surface of the abdomen. n n Indications: cancer, diverticulitis, imperforate anus, trauma, and a treatment for bowel dysfunction for spinal cord injured persons.

KEY POINTS n Effective/efficient bowel program promotes independence and improves quality of life n Prevents incontinence n Provides control over body function n Prevents healthcare problems

The End