Complex Bowel Conditions and Care

While bowel management is a standard component of personal patient support, those at risk of constipation or incontinence require a greater level of care so that their quality of life is not adversely affected.

What is Complex Bowel Care?

Bowel care is a regular component of personal support that is imperative to a patient’s quality of life (NDIS 2018; NHS 2017).

However, a patient at high risk of severe constipation or faecal incontinence may require complex bowel care from healthcare staff with a specialised skill set (NDIS 2018).

This care must be proportionate and appropriate for each patient’s individual needs (NDIS 2020).

Complex bowel care may include:

• Observing and recording changes in a patient’s bowel habits;
• Administering treatments such as enemas and suppositories;
• Identifying when the patient needs to be referred to a practitioner;
• Administering non-routine medication; and
• Understanding that bowel health is highly personal for the patient and supporting them accordingly.

(NDIS 2018)

Treatments used in complex bowel care may include:

• Oral aperients to relieve constipation;
• Suppositories;
• Enemas;
• Bowel irrigation;
• Manual removal;
• Digital stimulation; and
• Abdominal massage.

(ACARES 2019; ACIA 2017)

Complex Bowel Care NDIS Quality Indicators

Not only is complex bowel care essential to ensuring clients’ quality of life, it is also a requirement for NDIS (National Disability Insurance Scheme) providers under the NDIS Practice Standards and Quality Indicators module for High Intensity Daily Personal Activities.

Under these standards, care providers must meet the following quality indicators:

• Clients are enabled to participate in the assessment and development of a complex bowel care plan. This plan identifies possible risks, incidents and emergencies, and what actions need to be taken to manage these situations, including the escalation of care, if necessary. The client’s health status is reviewed regularly (with the patient’s consent).
• Staff providing complex bowel care are informed by appropriate policies, procedures and training plans.
• Staff providing complex bowel care have received all necessary training from a qualified health practitioner or another appropriately qualified individual.

(NDIS 2020)

Who May Require Complex Bowel Care?

Complex bowel care may be required for patients with mobility-limiting conditions. These include:

• Spinal injuries;
• Multiple sclerosis;
• Stroke;
• Neurological conditions;
• Cerebral palsy (with a Gross Motor Function Classification System (GMFCS) level of 3, 4 or 5); and
• Acquired brain injury.

(NHS 2017; NDIS 2018)

A patient who is receiving non-routine treatment such as PRN medication for bowel care may also require complex support (ACARES 2019).

The Physiology of Defecation

Defecation is considered a voluntary process prompted by the movement of faeces into the rectum. When the individual moves into a sitting or squatting position, the anorectal angle straightens and the external anal sphincter and puborectalis muscle relax (RCN 2019).

When abdominal pressure raises, the muscles of the anterior abdominal wall tense and shift this pressure to the pelvis. The stool enters the rectum and is pushed out by a spontaneous rectosigmoid contraction (RCN 2019).

Once the rectum is empty, the external sphincter closes in order to maintain continence (RCN 2019).

What Does Normal Defecation Look Like?

Normal defecation varies between individuals, ranging from three times per day to three times per week. The average faeces output per day is between 150 to 200 grams, however, consistency and production depend on gender, diet and health (RCN 2019).

The Bristol Stool Chart can be used to assess a patient’s bowel motions and determine whether there is any abnormal bowel function that requires intervention (Premium Health 2017).

Complex Bowel Issues

Complex bowel care may be required by patients who are at risk of severe constipation or faecal incontinence.

Constipation

Constipation refers to difficulty defecating over an extended period of time. It is defined as the occurrence of less than three bowel movements per week (Premium Health 2017).

A patient who is constipated may simply have difficulty defecating (with a normal defecation frequency), or they may have a delayed colonic transit time of food from the mouth to the anus, which causes stools to become hard, dry and infrequent (Premium Health 2017; RCN 2019).

There are three types of constipation:

1. Primary constipation has no pathological cause and may be associated with immobility, poor diet, delayed transit or pelvic floor abnormalities.
2. Secondary constipation is caused by a metabolic, psychological or neurological condition.
3. Functional constipation is a functional bowel disorder. It describes difficult, infrequent or incomplete defecation that has persisted for at least three to six months.

(RCN 2019)

Faecal Incontinence

The concept of continence refers to an individual’s ability to urinate and defecate voluntarily, hygienically and in a socially acceptable manner (NHS 2017).

A patient experiencing faecal incontinence has difficulty with bowel control, causing involuntary loss of stools. This can be highly embarrassing for the patient (RCN 2019). There are three types of faecal incontinence:

1. Faecal incontinence is the involuntary loss of stools (solid or liquid) in an unhygienic or socially problematic manner.
2. Anal incontinence is the involuntary loss of stools (solid or liquid) or flatus in an unhygienic or socially problematic manner.
3. Passive soiling is the leaking of stools (solid or liquid) from the anus without the patient’s knowledge. This can occur at any time.

(RCN 2019)

Causes of faecal incontinence include:

• External anal sphincter weakness or defect;
• Poor internal anal sphincter pressure;
• Diarrhoea;
• Inflammatory bowel disease;
• Irritable bowel syndrome;
• Rectal prolapse, fistula, haemorrhoids;
• Neurological disease;
• Poor toilet facilities;
• Poor diet; and
• Dependence on a carer.

(RCN 2019)

Managing Complex Bowel Issues

Note: Always refer to your facility’s policies on complex bowel care.

Generally, patients who are identified as requiring complex bowel care should be assessed by a suitable health practitioner. Together, the patient and health practitioner will establish a bowel management plan to guide the patient’s care staff. This should include an action plan that details how to escalate care in the event of an emergency and when to refer (ACARES 2019).

The goals of this bowel management plan are generally to:

• Assist patients to self-manage their bowel emptying regularly and in socially-appropriate contexts;
• Use the minimum level of intervention (physical and pharmacological) to achieve bowel emptying; and
• Prevent bowel accidents, constipation and other issues.

(ACARES 2019)

Quality of Life Living With Complex Bowel Conditions

Bowel health is essential to quality of life, and complex bowel conditions, especially faecal incontinence, can have profound social and emotional consequences. Therefore, the management and treatment of bowel conditions predominantly aim to improve QoL (NSW DoH 2016; Duyos & Ribas 2019).

Assessing the impact of bowel conditions requires patient input, however, many patients are reluctant and embarrassed to discuss bowel issues, sometimes even limiting their social lives and avoiding seeking treatment due to the stigma. It is reported that only 5 to 27% of people experiencing faecal incontinence report their symptoms to a physician (Duyos & Ribas 2019).

It is helpful for patients to share their experiences and be included in discussions about their treatment options. Ensure you communicate with them in an empathetic and sensitive manner so that they are comfortable discussing their symptoms without feeling judged (RCN 2019).

When to Refer

The patient should be referred to a health practitioner if they are experiencing the following complications:

• Overflow;
• Bowel obstruction;
• Perforation;
• Faecal impaction;
• Strangulated hernia;
• Infection;
• Autonomic dysreflexia;
• Undiagnosed rectal bleeding;
• Undiagnosed diarrhoea; and
• Poor nutrition or hydration.

(RCN 2019; NDIS 2018)

Conclusion

Despite significantly affecting patients’ quality of life, bowel health can be an embarrassing topic for many, hindering their ability to seek treatment. In order to identify bowel issues, provide complex bowel care and escalate treatment if necessary, it is essential to communicate with patients empathetically so that they feel comfortable addressing their concerns.

Note: When providing bowel care, always adhere to infection prevention precautions and use the appropriate PPE in order to minimise the risk of infection transmission.

Additional Resources

• ACARES, Complex Bowel Management
• NDIS Practice Standards: Skills Descriptors
• NDIS Practice Standards: NDIS Practice Standards and Quality Indicators
• NHS, Adult Bowel Care Guidelines
• Premium Health, Bowel Management Workbook
• RCN, Bowel Care Clinical Resource
• Continence Management in the Community
• Managing Constipation in the Older Adult

References

• The Australian Community Industry Alliance 2017, Provision of Bowel Care by Support Workers, The Australian Community Industry Alliance, viewed 10 June 2020, http://acia.net.au/wp-content/uploads/2018/10/ACIA-006-Provision-of-Bowel-Care-by-Support-Workers-3.pdf
• Accommodation & Care Solutions 2019, Complex Bowel Management, Accommodation & Care Solutions, viewed 10 June 2020, https://acares.com.au/wp-content/uploads/2019/06/POL-6.4-Complex-Bowel-Management-Policy.pdf
• Duyos, A M & Ribas, Y 2019, ‘Quality of Life Considerations on Fecal Incontinence’, Current Topics in Faecal Incontinence, viewed 11 June 2020, https://www.intechopen.com/books/current-topics-in-faecal-incontinence/quality-of-life-considerations-on-fecal-incontinence
• New South Wales Department of Health 2016, Bowel Care Guidelines, New South Wales Department of Health, viewed 11 June 2020, https://facs-web.squiz.cloud/__data/assets/pdf_file/0007/590686/059-Health-Planning-Bowel-Care-Guidelines-accessible.pdf
• NDIS Quality and Safeguards Commission 2020, NDIS Practice Standards: NDIS Practice Standards and Quality Indicators, NDIS Quality and Safeguards Commission, viewed 11 June 2020, https://www.ndiscommission.gov.au/sites/default/files/documents/2019-12/ndis-practice-standards-and-quality-indicators.pdf
• NDIS Quality and Safeguards Commission 2018, NDIS Practice Standards: Skills Descriptors, NDIS Quality and Safeguards Commission, viewed 10 June 2020, https://www.ndiscommission.gov.au/sites/default/files/documents/2018-09/high-intensity-skills-descriptors.pdf
• NHS 2017, Adult Bowel Care Guidelines, NHS, viewed 10 June 2020, http://www.southernhealth.nhs.uk/_resources/assets/attachment/full/0/118490.pdf
• Premium Health 2017, Bowel Management Workbook, Premium Health, viewed 10 June 2020, https://premiumhealth.com.au/wp-content/uploads/2017/07/Bowel-management-workbook-PHDBMWKB.15.pdf
• Royal College of Nursing 2019, Bowel Care, Royal College of Nursing, viewed 10 June 2020, https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/publications/2019/september/007-522.pdf?la=en