Ensuring a patient received appropriate bowel care following spinal cord injury.
The Use of a Case Study to Illustrate a Decision Made by a Nurse in a Clinical Setting
A problem–solving approach to nursing care has been taught in colleges of nursing for several years. This approach, usually described as the ‘ nursing process’ enables learners.
to develop skills which they can take with them into their professional lives as practitioners by identifying various needs and the problems thus raised when planning care, implementing those plans and then evaluating them. Such a nursing decision will affect present and future care. Elstein and Bordage studied this process in 1979. They concluded that physicians were aware of having both knowledge and experience and believed that they were using these to make decisions regarding clinical situations using what they perceived as an intuitive approach. The authors state that they were in fact using cognitive strategy – picking up clues and from these arriving at hypotheses with regard to the diagnosis. The physician then looks for further clues or cues and compares them with one or the other of the various hypotheses arrived at. In the same year, 1979, Eddy and Clanton, stressed the importance of finding one pivotal point which leads to a bridge to the knowledge the person has acquired.
The ways in which this point can be arrived at will vary. There will be a number of constraints and difficulties to be overcome before the correct decision is made. Communication for instance. If a patient cannot respond to questions for instance, as
may occur if they are unconscious or an infant, then a practitioner has to use other methods to arrive at the proper conclusions. Another constraint might be lack of training – a nurse could be aware of a possible solution, but if staff have received no training in the method progress ceases until this has been done and a satisfactory standard of practice can be achieved and maintained. The ideas and abilities of other members of the staff team may also be a constraint, although on other occasions these can have a positive and supportive effect.
A Case Study
Mr A, aged 30, has been involved in a road accident and has suffered an incomplete spinal cord severance at the level of the 6th thoracic vertebrae. He was being cared for in the rehabilitation ward of his local hospital. He spent eighteen months in hospital and was very dependent upon others for his bowel management because of his physical condition. An incomplete severing of the spinal cord means that Mr A’s spine has not totally lost its ability to convey neural messages to or from the brain. He retains some sensory function, but is not able to control the motor function of his bowel.
When it was almost time for his discharge a discharge planning meeting was arranged and the district nursing service was informed of the situation. While in hospital Mr A. was incontinent of faeces. This was treated there by giving glycerine suppositories each evening at 8 pm in an attempt to prevent constipation, because he was no longer able to feel the normal stimulus for a bowel action or to control the various muscles involved. Care at this time of the evening however would not take advantage of the natural gastro-colic reflex which can be helpful in bringing about a bowel action. Injuries to the spinal cord between lumber vertebra one and sacral vertebra 5 usually result in a flaccidity in the bowel. It is therefore likely that laxatives are required in order to stimulate bowel action, and may also require manual evacuation of faeces from the rectum. In cases such as Mr A’s where the injury is higher, i.e. higher than thoracic 12, the result may be a reflex bowel i.e the bowel opens at any time the rectum is full whether or not this is convenient.
This reflex can be stimulated in several ways – either mechanically or by chemical action, in order to trigger the anal sphincters to dilate, and so initiate the act of defecation. According to Coggrave et al ( 2009) digital removal of faeces may be needed. In Mr A’s case phosphate enemas were also used as constipation remained a problem. Coggrave et al ( 2009) state that the aim of the proper management of bowel movements is to “achieve regular, predictable emptying, at a socially acceptable time and place, avoiding constipation and unplanned evacuations”
In order to achieve a bowel movement the bowel must absorb water so adequate fluid levels must be maintained. There must be co-ordinated contractions to move the faeces for short distances and larger contractions in order to bring the faeces down into the rectum and so to the point of evacuation. Effective management of the symptoms rely on a detailed assessment, which would include a review of the causes and the history of both symptoms and previous interventions. Also included would be the impact the symptoms have on the person’s ability to function and the impact this has on staff. ( Symptom Management , Guidelines for a Palliative Approach in Residential Aged Care, undated) It would be usual in a case of spinal cord injury, such as Mr A’s,for adequate bowel management to be achieved before discharge, but this had not been achieved.
An individualized nursing plan with regard to bowel management must be based upon evidence and so a number of questions need to be answered. These would include such things as how often and when does the person eliminate faeces? Do certain things, .e.g hot drinks, bring on a bout of faecal incontinence? What is the person’s attitude to the way in which elimination is at present taking place? What long term problems have there been and how were these managed? What problems does the person have with faecal elimination at present? ( Roper, Logan and Tierney, 1990, page 204). Nurses should be aware of best practice in cases such as this, but also be aware that it may be necessary to make changes to procedures used according to particular situations and advances in available technology.
It was felt that better management of bowel movements was a priority in Mr A’s case as not only was his lack of control inconvenient , both to him and to staff, it was also causing embarrassment and, as far as staff was concerned was causing some resentment. Coggrave et al ( 2009) also point out that phosphate enemas should not be a method of choice in cases of spinal cord injuries because their use can result in damage to the rectum, cannot be retained effectively, and also because they can bring on autonomic dysreflexia i.e. an abnormal response to stimuli such as pain which can occur in someone who has an injury at Thoracic 6 or above. Wiesel and Bell, 2004 point out that this can cause headaches, but also a potentially fatal rise in the blood pressure. According to Grundy and Cumming (1996) other symptoms are bradycardia, chills and sweating, a blurring of the vision and bronchospasm. This danger coupled with the relative lack of control obtained with this method it was therefore decided that there must be changes made to the methods used to control Mr A’s bowel movements. A change from a dependent model to a more independent one is needed which would involve
a change in his habits of elimination, an alteration of the method used to bring about elimination, and a change in daily routine. (Roper, Logan and Teirney, 1990, page 204) This means that the problem had been identified , relevant information had been collected and a knowledgeable assessment of the situation could be made. Various options could then be considered and their advantages and disadvantages evaluated. A decision to try to particular course of action can then be made. It can then be put into action and, after a suitable period this is revalulated as to its degree of success or failure, and, if felt to be necessary, any required changes can be made. Another point in this particular case is that , because of the change from a hospital situation to a community one, the present care plan needed alteration because it could not be sustained following discharge. Fully independent bowel care was not a viable option in Mr A’s case because of the permanent nature of his condition. It was therefore necessary for plans for future community care to be decided before discharge. This was a joint decision made at the discharge planning meeting, which included both hospital staff who were familiar with Mr A and a junior representative of the district nursing team. The plan chosen needed to be both sustainable and acceptable to those involved. (Coggrave et al, 2009) The Primary Care Trust evening nursing service was only meant to used in emergencies and cases of palliative care. This meant that evening bowel care could not be continued on a regular basis as it had been in the hospital situation.
The conservative management of bowel action includes such factors as being aware of diet and fluid intake and assessing how these affect the bowel. Such management also makes use of the body’s natural gastro- colic reflex. This means that it initiates an evacuation of the bowel after the person concerned has eaten or drunk liquid – effectively pushing things on. Other processes that may help would include abdominal massage and digital stimulation of the anal sphincter. Coggrave et al ( 2009) point to the fact that
there is little evidence to support these measures.
Injuries such as Mr A has received can result in a number of difficulties such as the inability to carry out routine household tasks, the ability to work, to perform sexually and to carry out personal hygiene. In this case study the emphasis will be on Mr A’s inability to control his bowel movements.
Once he had returned home Mr A’ was soon seen by some as a problem patient and a complainer, particularly by more junior staff. Part of the problem was that Mr A received bowel care early in the day, at 8.30 am. Digital stimulation was used, but it could on occasions take well over an hour to complete bowel care and then Mr A would perceive sensations of having a full rectum later in the day, and also had fairly frequent bouts of faecal incontinence. Another problem was embarrassment as the stimulation caused Mr A to experience erections. Bowel care is often considered to be a low priority ( Coggrave et al, 2006) At the same time those who have problems with incontinence may be unpopular with those who care for them. ( Stockwell 1972)
A change of treatment from suppositories to Microlax enemas was decided upon. These soften the stool and work in about 30 minutes. They include a combination of ‘sodium citrate dihydrate, sodium lauryl sulfoacetate, glycerin, sorbitol and sorbic acid, and distilled water’ (Pharmacia & Upjohn) , these being less problematic than the continued use of phosphate enemas. However any chemical based enemas, if used for a long period, can lead to electrolyte imbalances, loss of vitamins and even strain on the liver ( Optimal Heathcare.com , 2002)
These enemas would be accompanied by the administration of a stimulating laxative each evening. This decision to change this care plan was based upon the abilty of staff to arrive at a solution to a clinical situation using pattern recognition and similarity i.e. other patients had been treated in this way. Benner and Tanner ( 1987 ) would describe such choices as intuitive. Intuitive decision making will include perhaps more creative choices, but the person has to trust their own intuition. They can do this by considering all possible risks and consequences and possible rewards. ( Umiker 1989)
This new attempt at management of the problem proved however to be ineffective. Glickmann and Kamm, (1996) suggest that poorly managed bowel movements can lead to a negative impact upon a person’s quality of life.
In order to facilitate a fully effective method of bowel continence any nursing interventions must be based upon current evidence and making an assessment of the situation in order both to evaluate the present methods being used and to consider evidence based positive outcomes i.e. how did the present care plan work? In what ways could it be altered in order to achieve a more positive result, that is to achieve a higher standard of faecal continence management. Also to be taken into consideration were the patient’s daily routine, what he was capable of achieving independently and what things he remained incapable of doing. What coping methods were being used? The nurse may be able to recognise problems that the patient is unaware of – e.g. that overuse of enemas can lead to electrolyte imbalances. It was necessary to both work towards alleviating problems and to help Mr A to cope with the part of the problem that could not be changed – his inability to independently control bowel movements.
It was hoped that the method eventually chosen would have a positive effect upon bowel management , but would also have positive psychological effects for Mr A, improving his social abilities , as well as improving his relationships with those members of staff who found him difficult. I t would also eliminate the need for more care to be given later in the day
Taking all this into consideration, and having previously successfully used anal irrigation with an earlier patient with similar problems , it was decided after consultation with staff and with Mr A, to use this method for a trial period. Peristeen was the chosen product. This was an evidence based decision having taken into consideration both previous experience with this method and Mr A’s particular situation. Peristeen is designed for use in anal irrigation, whether by the carer or the person themselves. The method is a recognised technique for bowel management , to be used after conservative therapies have been tried and have failed to achieve a satisfactory result, but before surgery is resorted to. (National Institute for Health and Clinical Excellence, 2007, (Royal College of Nursing, 2008) It is one suitable for long term sustained use and so suitable for a young man with a life time problem. I t is a better solution than the long term use of laxatives, which can lead to symptoms such as bloating, nausea, cramping and loose stools. ( American Association of Family Physicians, 2005)
A hand pump replaces the normal physiological action of gravity. It is particularly suitable in cases where there is limited manual ability and dexterity. Staff involved required training in the new procedure. Bowel care policy needed to be considered and updated in order that standards were standardised at a suitable level. This could take time, but an interim policy was drawn up in order that treatment could begin. The treatment is considered to be a complex one and so the patient’s written consent was obtained.
Appropriate nursing interventions must include being able to solve or alleviate problems ( Roper, Logan and Tierney, 1990, page 262) as well as developing suitable mechanisms of coping for those situations where the problem – in this case the spinal injury which resulted in lack of bowel control – cannot be solved. I t is important that nurses make decisions in such cases in the best way possible – based upon knowledge, skills, resources, needs and appropriateness. Nurses need to be able to identify relevant issues involved when a nursing decision is required. This includes the diagnosis, and all factors which are contributing to an altered function regarding continence. Only then can they arrive at a possible useful intervention, which must be chosen because it suits local circumstances, including the availability of resources, staff skills and the needs and
co-operation of the patient.
After careful consideration of various possibilities, and the particular case of Mr A, anal irrigation was chosen as the best option having first tried more conservative methods and before major surgery became the only possible option if improvement were to be achieved. A retrospective submission was made to the Primary Care Trust’s risk and governance committee. The committee were then able to introduce a protocol for introducing this new technology and the respective methods of care needed. This new protocol will mean that staff training and the monitoring of patients who use anal irrigation is now ongoing. The protocol also states that anal irrigation as a means of bowel management should only be considered after conservative measures have been tried unsuccessfully. It also specifies the information to be given to patients and it ensures that those using this particular procedure do so under the guidance of the continence service.
Using this method of anal irrigation reduced the distressing incidence of faecal incontinence and the accompanying constipation. This improved Mr A’s self esteem and the quality of life experienced with regard to his bowel actions and care and so fits in with the model of nursing care described by Roper, Logan and Tierney ( 1990) based upon activities of daily living. He no longer needed to phone for help later in the day and had more autonomy. Also the time required for care was reduced and it was done in a way that was more acceptable to both staff and patient. The choice of anal irrigation was not an immediately obvious one, as is evidenced by the fact that other methods had tried first. This meant that staff had be aware that there is not always only one possible solution to a problem, but also that traditional methods may need reconsideration , especially in the light of advances in medical technology and thinking.
This decision meant that both Mr A and the staff concerned benefited, because a correct decision was arrived at, based upon previous experience and knowledge as well as an appreciation of the particular problem in Mr A’s case.
AMERICAN ASSOCIATION OF FAMILY PHYSICIANS, 2005, Laxatives OTC
products for Constipation, available from http://familydoctor.org/online/famdocen/home/otc-center/otc-medicines/861.html ( accessed 26th January 2011)
BENNER,P. and TANNER,C.,1987, Clinical judgement: how expert nurses use intuition, American Journal of Nursing, January: 23-31.
COGGRAVE, M. et al (2006) Progressive protocol in the bowel management of spinal cord injuries. British Journal of Nursing; 15: 20, 1108-1113.
COGRAVE, M. and NORTON,C. (2009) Teaching transanal irrigation for functional bowel disorders. British Journal of Nursing; 18: 4, 219-224.
EDDY,D. and CLANTON,C., 1979 The art of diagnosis: solving the clinicopathological exercise, in ‘Professional Judgement : A Reader in Clinical Decision Making’ J. DOWIE and A. ELSTEIN., editors, 1988, Cambridge, Cambridge University Press, pages 200-211
ELSTEIN, A. and BORDAGE ,G., 1979, Psychology of Clinical Reasoning, in Professional Judgement : A Reader in Clinical Decision Making’ J. DOWIE and A. ELSTEIN., editors, , 1988, Cambridge, Cambridge University Press, pages 109- 129
GLICKMANN, S. and KAMM, M., 1996, Bowel dysfunction in spinal-cord-injury patients. Lancet; 347: 9016: 1651.
GRUNDY, D and CUMMING J. 1996 Urological management. In: Grundy D, Swain A (editors ) ABC of Spinal Cord Injury. London: British Medical Journal Publishing Group.
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (2007) Faecal Incontinence. The Management of Faecal Incontinence in Adults. London:
OPTIMAL HEALTHCARE, 2002, Chemical enemas, available from http://www.enemabag.com/enema_solutions.html#chemical_enema ( accessed 26th January 2011
PALLIATIVE CARE AUSTRALIA, undated, Symptom Management , Guidelines for a Palliative Approach in Residential Aged Care, available from http://agedcare.palliativecare.org.au/LinkClick.aspx?fileticket=B%2FeKER8lbAo%3D&tabid=825&mid=1378 ( accessed 26th January 2011)
PHARMACIA and UPJOHN, Microlax, undated, available from http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20M)/MICROLAX.html
( accessed 26th January 2011)
ROPER,N., LOGAN,W. and TIERNEY, A. 1990, The Elements of Nursing, based on a model of living, Edinburgh, Churchill Livingstone.
ROYAL COLLEGE OF NURSING ,2008, Bowel Care, Including Digital Rectal Examination and Manual Removal of Faeces. London: Royal College of Nursing
STOCKWELL, F. 1972 The Unpopular Patient. The Study of Nursing Care. London , Royal College of Nursing
UMIKER,W., 1989, Intuitive decision making and problem solving, The Free Library, available from
http://www.thefreelibrary.com/Intuitive+decision+making+and+problem+solving.-a07530291, \9 accessed 26th January 2011
WEISEL, P. and BELL,S (2004) Bowel dysfunction: assessment and management in the neurological patient. In: NORTON,C. and CHELVANAVAGAM,S., (editors) Bowel Continence Nursing. Beaconsfield: Beaconsfield Publishers.