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BOWEL PROGRAM IN SPINAL CORD INJURY: BOWEL MOVEMENTS/BOWEL PROGRAM IN SCI

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   After a spinal cord injury, messages from the rectum do not get through to the brain and you do not get the urge to have a bowel movement. As a result of not feeling the urge, the coordination to have a bowel movement is lost. The brain is unable to send a message to the sphincter to either relax or hold on until later. However, the reflexes remain intact and that is why a bowel program is important.

   You may wonder if you can ever get back into a normal routine again. You can! It is possible to develop a regular bowel program that will avoid daily accidents, but you have to learn how to do this. Your nurse will help you work out the best possible bowel program for you.

The goals of the bowel program are:

  • to have a bowel movement at a predictable time
  • to promote stool consistency that allows for easy passage.

The factors of a successful bowel program are:

  • A routine of using a suppository every other day (morning or evening), but most importantly at the same time; best 1-2 hours after eating.
  • Choose foods high in fiber (roughage), such as fresh fruits, vegetables, and whole grain foods.
  • Drink enough liquids to keep the stool a soft formed consistency and/or use a stool softener. Prune juice is a great natural laxative.
  • Eat yogurt and probiotics (acidophilous) to promote healthy intestinal flora.
  • Avoid foods which cause constipation, or very hard stools, such as meats and dairy products which are low in fiber or roughage.
  • Avoid foods which cause diarrhea, or very loose stools, such as spicy, greasy foods, onions, etc.
  • Be as active as you can. The lack of activity can cause constipation.
  • Drink a cup of hot fluid (tea, coffee) to help initiate bowel movement.
  • Use a commode chair or toilet.

   Learn, by experimenting, the foods and lifestyles that let you have bowel movements at a predictable time. Once you are having regular bowel movements, stick to the bowel program you developed. Skipping your program can cause constipation, impaction, and bowel accidents. If something is wrong with your program, it is usually related to diet and/or activity. Remember to think about what you eat, drink, and do if a difficulty occurs.

   When you are discharged from the hospital, you may decide to change your program to fit your lifestyle. If you have learned the things that work, and do not work for you, you will be able to make changes with a minimum amount of discomfort.

The bowel program procedure is as follows:

  1. Assemble equipment:

    -Blue pads
    -suppositories
    -non-sterile gloves
    -lubricant
    -commode, toilet or bed
    -wet wash cloths or baby wipes
    -towel

  2. Position on your left side in bed

  3. Place 2 blue pads behind your buttocks

  4. Put on gloves, lubricate your index finger and begin digital stimulation to remove any stool in your rectum

  5. When ALL the stool in the rectum is removed, insert 2 suppositories as far as you can into the rectum along the bowel wall

  6. Wait in bed on your left side 15-45 minutes. (Time varies for each individual)

  7. Transfer to bedside commode or toilet (via w/c)

  8. Sit for 15-20 minutes doing digital stimulation 2 or 3 times if necessary

  9. Note size, consistency and color of stool

  10. Clean yourself with baby wipes or wash cloth

 

In lower injuries the bowel may be termed a "flaccid" bowel in which there is a loss of reflex and the sphincter does not work. A bowel program using suppositories will not be effective. In these cases manual removal of the stool will need to be done daily and at the same time to maintain a healthy bowel.

The medications and stimulants used in managing your bowel program are:

PRODUCT/
EXAMPLE
WHAT IT DOES INFORMATION
Suppositories

Glycerine when effective; it is cheaper for long-term use.

Bisacodyl

Magic Bullet

To set off reflexes that start movement of lower colon and rectum.
Glycerine irritates rectum mechanically and causes bowel movement.
Bisacodyl takes effect when it comes into contact with the intestinal wall and stimulates nerve endings there.
Some patients are able to stop using suppositories and then digital stimulation (with gloved, lubricated finger) may be all that's needed

Many people need to use Bisacodyl at first, but then are able to switch to Glycerine.

Stool Softeners

Docusate

To soften stool (to avoid impaction or constipation)

You may not need them if your diet and fluids are adequate.

If stool softeners are going to work, you must drink plenty of fluids. If stool becomes too soft, you may have unscheduled bowel movement. What to do: stop stool softener or decrease dosage for a short period. Start again when stool is firm enough again.
Peristaltic Stimulators and Stool Softeners

Docusate with Casanthrol

To stimulate the normal wave-like movement of the bowel which propels stool through the bowel. If you're having loose or unscheduled bowel movements, medicine will need to be decreased or stopped.
Bulk Formers

Metamucil

To increase amount of material in intestine.

Amount prescribed is taken in a glass of water once or twice daily. Drink plenty of liquids when taking Metamucil.

TheravacMiniEnema To set off reflexes that start movement of bowel, colon, and rectum To administer: pinprick neck of enema bulb only. (Never cut, may tear rectal lining); with gloved, lubricated finger, gently squeeze contents into rectal vault-allow 20 to 30 min. for complete evacuation.
Nupercainal ointment To prevent acute symptoms if hyperreflexia is a problem. It may delay bowel movement; insert into rectum 5-10 minutes prior to inserting suppository, using digital stimulation or manual removal.
Enema

Fleets enema or oil retention enema in 4 ½ oz tube.

Use only if you are very constipated. 1. If you make your own enema, never use more than two cups (500cc); one cup should be enough
2. Do not use routinely; can decrease bowel tone.
Laxatives

Milk of Magnesia

Use only for severe constipation or if your doctor orders. They upset a bowel program as they can cause much of bowel to empty; can cause unscheduled bowel movement.

There are many herbal products available on the market. If you choose to use one, let your doctor know. There are also other medications that your doctor may prescribe for you.


Bowel problems include:

Constipation: dry, hard stool that is difficult to expel because it is stuck in the lower intestine. The stool can appear like small round pellets or balls.

  • Causes include lack of stool softeners, not using suppositories, lack of adequate fluid intake, lack of exercise and certain foods such as rice, potatoes, pasta, cheese, bananas
  • Signs of constipation are no results from two bowel programs done two days in a row, hard or distended abdomen, pain and discomfort, lack of appetite, persistent diarrhea, nausea
  • Treatment includes add roughage to diet, increase stool softeners, increase fluids, increase exercise and take a laxative and repeat bowel program

 

Diarrhea: loose water stools, and can be caused by flu, illness, medications and foods, and can be a sign of impaction.

  • Causes include high anxiety, occasionally antibiotics or other medications, constipation and certain foods such as papayas, mangoes, excessive alcohol intake, beans.
  • Treatment includes decrease anxiety, disimpact if you think you are impacted, eliminate foods that cause you to have diarrhea, limit alcohol intake.

Call your doctor if constipation or diarrhea continues.

 

Hemorrhoids: condition in which the veins in and around the anus or lower rectum become inflamed and swollen. They can begin to itch, bleed and cause pain. They can be internal or external. The best way to prevent hemorrhoids is to keep stools soft so they can pass easily. Many creams are available to decrease the symptoms however in some cases they may have to be surgically removed.

 

Severe Impactions:

  • Magnesium Citrate or a Isosmotic bowel cleanser may be prescribed to cleanse the bowel due to severe impaction.
  • A PIE procedure (Pulsed Irrigation Evacuation) may also be ordered to clear fecal impactions using pulses of warm water in controlled amounts to hydrate stool and improve peristalsis.
  • A colostomy my be performed in extreme cases. A colostomy is a cut in the large intestine to create an artificial opening to the exterior of the abdomen. It serves as an artificial anus in which bowel movements fall into a collection pouch that is anchored to the abdominal skin.

 

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