Although only a small number of patients require DRF, it is an essential part of their care and all NHS organisations must have a policy for manual bowel evacuation
Defecation is essential to enable us to eliminate waste and keep our bowels functioning. In some individuals, defecation is not possible without an intervention. This might be oral medication, such as laxatives to soften the stool and propel the faeces round the colon, or digital removal of faeces (DRF) by a competent health professional on a regular basis. This article considers who needs DRF, who can carry it out, the ethical and legal implications, and the importance of appropriate bowel care being carried out in all care settings.
Citation: Ness W (2013) Digital removal of faeces. Nursing Times; 109: 17/18, 18-20.
Author: Wendy Ness is colorectal nurse specialist at Croydon University Hospital.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF including any tables and figures
With newer bowel care techniques, such as transanal irrigation, digital removal of faeces (DRF) is not often needed. However, for a small group of patients - such as some who have sustained a spinal cord injury (SCI) or have a neurological condition such as multiple sclerosis - it is an essential part of their bowel-care routine (Box 1).
Aside from this, DRF may also be used as an acute intervention for patients who have impaction of stool that cannot be resolved with medication. Symptoms of impaction may include: absent or reduced evacuation of stool; abdominal bloating or distension; nausea; and pain. It may be accompanied by overflow or spurious diarrhoea, in which looser stools leak around an unmoving faecal mass, often associated with faecal soiling (Multidisciplinary Association of Spinal Cord Injury Professionals, 2012).
Box 1. Circumstances necessitating DRF
- When other methods of bowel emptying fail or are inappropriate
- Faecal impaction or loading
- Incomplete defecation
- Inability to defecate
- Neurogenic bowel dysfunction
- Bowel management with specific patients following spinal cord injury
Source: Royal College of Nursing (2012)
Who can carry out DRF?
DRF can be both uncomfortable and embarrassing for patients (Association for Continence Advice, 2011), so receiving well informed and compassionate care for this is essential (Coggrave, 2010). It is recommended that only health professionals who can demonstrate competence to the level determined by the Nursing and Midwifery Council (2008) should carry out this procedure; however, a qualified nurse who can demonstrate competence to this professional level may be expected to delegate care delivery to others who are not registered, such as healthcare assistants or carers. Such delegation must not compromise existing care, but must be directed to meeting the needs and serving the interests of patients (Royal College of Nursing, 2012).
All nurses should have successfully completed bowel-dysfunction training that includes theoretical and practical aspects of digital rectal examination (DRE) and DRF. Ideally this training should be based on the RCN (2012) guidelines and Skills for Health’s National Occupational Standards on bowel dysfunction (Box 2).
Box 2. bowel dysfunction competencies
- CC01 – Assess bladder and bowel dysfunction
- CC08 – Care for individuals using containment products
- CC09 – Enable individuals to effectively evacuate their bowels
- CC12 – Enable individuals to undertake pelvic-floor muscle exercises
- CC13 – Enable individuals with complex pelvic-floor dysfunction to undertake pelvic-floor muscle rehabilitation
Source: Skills for health
Assessment and legal considerations
DRF is an invasive procedure and should only be performed when necessary, after individual assessment and taking religious and cultural beliefs into consideration (RCN, 2012). Before initiating any bowel-emptying technique, health professionals must explain to their patients what the intervention involves, including expected outcomes, side-effects and complications (Foxley, 2009). Valid consent must be obtained; this reflects patients’ right to determine what happens to their own body and is a fundamental part of good practice. Health professionals who do not respect this principle may be liable for legal action by the patient and by their professional body (Department of Health, 2009).
When performing DRF as an acute intervention or part of a regular package of care it is important to carry out an individualised risk assessment. The following should be checked:
Blood pressure in patients with an SCI who are at risk of autonomic dysreflexia (AD), before and at the end of the procedure (Box 3) - a baseline blood pressure is advised for comparison. In patients for whom SCI is a routine intervention and tolerance is well established, the routine recording of blood pressure is not necessary;
- Signs of distress, pain, discomfort;
- Stool consistency (RCN, 2012).
Box 3. Autonomic dysreflexia
Autonomic dysreflexia (AD) occurs only in people with spinal cord injuries at or above the T6 level. It is related to disconnections between the body below the injury and the control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to potentially dangerous levels.
Common causes include:
- Full bladder
- Bladder infection
- Severe constipation
- Pressure ulcers
- Anything that would normally cause pain or discomfort below the level of the spinal cord injury can trigger dysreflexia
Symptoms include a raised blood pressure resulting in:
- Pounding headache
- Spots before the eyes
- Blurred vision
Other symptoms include:
- Flushing of the skin
- Some patients describe nasal stuffiness and will feel very anxious
- Uncontrolled AD can cause a stroke if not treated
- Remove the reason for the stimulation
- Check for distended bladder/full bowel; sit the patient up to decrease blood pressure
- Administer prescribed medication to reduce blood pressure if necessary
- Seek medical advice
Adapted from Spinal Cord Injury Network
When DRF is essential
If DRF is part of the patient’s bowel care it is essential the routine is not interrupted, regardless of the setting in which care is provided (RCN, 2012). This is imperative for those with an SCI who are at risk of AD; this can result in the bowel becoming distended due to constipation or impaction and is considered a medical emergency. Outcomes can include cerebral haemorrhage, seizures and cardiac arrest (National Reporting and Learning Service, 2004). Failing to support patients with an SCI who need DRF, results in ineffective bowel management (RCN, 2012).
The NRLS (2004) reported that DRF is rarely undertaken in NHS acute trusts and is unfamiliar to many nurses; it therefore recommends that NHS organisations providing acute care should:
- Have a policy for manual bowel evacuation;
- Ensure nursing staff in all care areas are aware of:
- The risks associated with these patients developing constipation or an impacted bowel;
- The potentially harmful outcomes of developing AD;
- How to access staff able to undertake a manual evacuation;
- Ensure experienced staff are available to undertake and teach the procedure;
- Recognise that these patients are experts in managing their own bowel care.
Other bowel-emptying techniques
As suggested earlier, patients may rely on other mechanical ways of emptying their bowels, such as digital rectal stimulation (DRS) or transanal irrigation, which reduces the need for DRF and (if appropriate) may be more acceptable options for the individual.
DRS triggers peristalsis of the left colon. It is performed by the patient or nurse/carer by gently inserting a gloved, lubricated finger into the rectum and slowly rotating the finger in a circular movement against the rectal mucosa. Rotation is continued until relaxation of the bowel wall is felt, flatus passes, stool passes or the internal anal sphincter contracts. It should be continued for 20 seconds then repeated every 5-10 minutes until stool evacuation is achieved (Wiesal and Bell, 2004).
Transanal irrigation with warm water is used to facilitate evacuation of stool from the descending colon and rectum. It can be used in a number of clinical scenarios, such as chronic constipation, faecal incontinence, and obstructive defecation secondary to, for example, a rectocele or neurogenic bowel dysfunction (RCN, 2012).
With a wide range of bowel-emptying techniques now available, the need for DRF is sometimes questioned; however it remains imperative in a small group of patients. These patients need seamless care, regardless of the setting. Failure to provide this could result in ineffective bowel management and could even be fatal if the patient experiences AD. Nurses need to acknowledge this important area of care, and understand that DRF, DRE and DRS are nursing roles. They must be able to access theoretical and practical bowel dysfunction training, including that for DRE and DRF, whether it is within their own trust or provided by an outside agency.
- Digital removal of faeces (DRF) can be used as an acute intervention for patients who have impaction of stool that cannot be resolved with medication
- Symptoms of impaction may include: absent or reduced stool evacuation; abdominal bloating/distension; nausea; and pain
- DRF is rarely undertaken in NHS acute settings and many nurses are unfamiliar with the procedure
- If DRF is part of the individual’s bowel care, it is essential that the routine is not interrupted
- Failing to support those people with a spinal cord injury who need DRF results in ineffective bowel management
Association for Continence Advice (2011) Guidance for End of Life/Palliative Continence Care. Bathgate: ACA.
Coggrave M (2010) Guidelines for neurogenic bowel management after spinal injury: better management of neurogenic bowel dysfunction supplement. Gastrointestinal Nursing; 8: 2, 7-9.
Department of Health (2009) Reference Guide to Consent for Examination or Treatment. London: DH.
Foxley S (2009) Bowel care for patients with long-term chronic conditions. Continence UK; 3: 4, 22-29.
Multidisciplinary Association of Spinal Cord Injury Professionals (2012) Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions.
National Reporting and Learning Service (2004) Patient Safety Information: Spinal Cord Lesion and Bowel Care.
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
Royal College of Nursing (2012) Management of Lower Bowel Dysfunction, Including DRE and DRF: A Guidance for Nurses. London: RCN.
Wiesal P, Bell S (2004) Bowel dysfunction: assessment and management in the neurological patient. In: Norton C, Chelvanayagam S (2004) Bowel Continence Nursing. Beaconsfield: Beaconsfield Publishers Ltd.