This article outlines the prevalence of bowel disorders, the assessment of bower dysfunction and the tools used to collect data for assessment
Ness, W. (2009) Using national guidelines to assess lower bowel dysfunction. Nursing Times; 105: 12, 16–17.
This guided learning unit outlines how national guidelines can support the assessment of bowel function. It discusses the prevalence of bowel disorders, the tools used to collect data for assessment and outlines how to carry out an assessment.
Keywords: Lower Bowel Dysfunction, Assessment, Gastrointestinal
Wendy Ness, MSc, RN, is colorectal nurse specialist, Mayday University Hospital, Croydon.
1. Know about the different tools used in the process of assessment.
2. Identify the effect that faecal incontinence may have on a patient’s quality of life.
Patients with bowel dysfunction require an extensive assessment to establish a differential diagnosis that will inform a patient-centred individual treatment plan.
There has been little guidance about the assessment of patients with bowel dysfunction. Continence assessment forms often focus on bladder dysfunction.
However, the profile of patients with bowel dysfunction has been raised with the publication of NICE (2007) guidelines on faecal incontinence and the Skills for Health (SfH) (2008) national occupational standards (NOS) for continence care, of which five relate to bowel dysfunction.
The RCN (2008) guidance for nurses on bowel care provides a review of lower bowel dysfunction in adults, expanding on the SfH competences relating to lower bowel dysfunction in a more usable format. It is currently being reviewed and updated.
These documents are aimed at all healthcare professionals and can be used as a benchmark. They provide support for those developing policies and procedures and influence the care of patients with bowel dysfunction. This article on assessment incorporates these documents/guidelines, which are drivers to improving bowel care in all settings.
Faecal incontinence (FI) in adults is estimated to affect 2% of the population (Perry et al, 2002). Anal incontinence occurs more frequently in women than men and its incidence is grossly underestimated because of under-reporting (Sultan and Thakar, 2002). FI can dramatically disrupt people’s lives because they are unable to control the passage of faeces or flatus (Rockwood et al, 2000).
Depending on the individual’s continence status, diarrhoea may affect one person more than another. Patients may have acute diarrhoea which lasts for 2–3 days or a more chronic problem that could be caused by, for example, food intolerance or Clostridium difficile.
Most people apply the term diarrhoea to loose or watery stools. Thus stool form, not frequency, defines diarrhoea. How often a symptom must occur for it to be considered significant depends on how bothersome it is to the patient (Longstreth et al, 2006).
Functional constipation is a bowel disorder that presents as persistently difficult, infrequent or seemingly incomplete defecation (Longstreth et al, 2006). It is estimated to affect one-third of the population in western industrialised countries (Klaschik et al, 2003). As with faecal incontinence, people experiencing constipation generally experience an impaired quality of life compared with the general population (Norton, 2006).
There is a debate over whether bowel and bladder function should be assessed separately. Kapoor et al (2008) found that, of 113 women who presented to a multidisciplinary pelvic floor clinic, 33 had combined urinary and faecal incontinence.
The assessment standard of the NOS for continence (CC01) addresses both bladder and bowel dysfunction to encourage health professionals to give consideration to both problems (Addison, 2002).
Tools used to collect data for assessment
For a first planned assessment of bowel function, there are a number of tools that can be used to collect data about a patient, including a self-assessment questionnaire with stool and food diaries that can be completed before the clinic appointment.
There are advantages and disadvantages to self-assessment. Some advantages are that it:
- Allows the patient to think about their bowel problem and how it affects their quality of life in the comfort of their own home;
- Saves time for healthcare professionals, allowing them to concentrate on problem areas;
- Is cost-effective as it reduces the time patients spend in clinic;
- Allows more time to plan care and discuss this with the patient;
- A patient may not admit in person to using their fingers to help empty their bowel, either by performing a manual evacuation of faeces or supporting the perineum. However, if this is referred to on a form they will become aware that it is something that other people may do.
Some disadvantages of self-assessment are that:
- Patients may not be able to read or understand;
- It may increase anxiety;
- Patients may find it time-consuming.
Who should carry out the assessment?
Koch and Hudson (2000) suggested that poor nursing assessment can result in poor management of patients with bowel dysfunction or altered bowel habit.
The Department of Health (2001) suggested that ‘patients are assessed by professionals who have specific continence training’. NICE (2007) recommended that ‘people who report to have faecal incontinence should be offered care to be managed by healthcare professionals who have the relevant skills, training and experience’.
Healthcare professionals need to be competent to carry out an initial detailed assessment and the NOS CC01 Assess Bladder and Bowel Dysfunction (Skills for Health, 2008) sets out the performance criteria required (Box 1).
Box 1. Performance criteria for assessing bladder and bowel dysfunction
1. Identify those at risk of having bladder and/or bowel dysfunction and initiate the continence assessment.
2. Respect the patient’s privacy, dignity, wishes and beliefs, and seek to minimise embarrassment during the assessment.
3. Seek to reduce any communication barriers with patients and relevant others.
4. Explain the continence assessment and obtain consent.
5. Ask the patient to explain their bladder and/or bowel condition and its history in their own words or obtain the history from an appropriate person accompanying them.
6. Seek to obtain a condition-specific history from the patient.
7. Obtain a list of the patient’s medication, the rationale for use and the impact on bladder and/or bowel activity.
8. Assess the impact of bladder and/or bowel dysfunction on the patient’s lifestyle and quality of life.
9. Carry out baseline observations and tests, where necessary, to support the assessment.
10. Review and interpret charts and questionnairesto inform the assessment.
11. Carry out and interpret a systematic clinical examination as required.
12. Discuss with the patient and their carer(s) the:
- Findings of the assessment;
- Likely causes;
- Implications (prognosis);
- Risks and priorities identified;
- Your conclusion and differential diagnosis;
- Need for any further investigations.
13. Initiate further investigations and referral.
14. Provide the patient with relevant information and advice related to their condition and any further investigations.
15. Make a full, clear record of the assessment and any agreed follow-up action.
Source: Adapted from Skills for Health (2008)
What to include in the assessment for bowel dysfunction
Before assessing the patient, it is imperative that informed consent is gained and, due to the sensitivity of the problem, if there is a carer or relative present that the patient is happy for them to be involved. (NICE, 2007).
The environment needs to be conducive to the patient’s needs and to ensure that, where possible, their privacy and dignity is maintained. The assessment should be carried out with sensitivity to minimise the patient’s embarrassment.
It is essential to collect a thorough medical and social history. For example, an obstetric history will identify problems associated with childbirth that can have long-term consequences for bowel function. Equally, assessment of drug history may identify excessive use of over-the-counter laxatives or drugs that can cause constipation, such as analgesics containing codeine. Neurological problems such as multiple sclerosis, Parkinson’s disease, spina bifida or spinal injury may result in bowel problems.
Details of information to collect about bowel dysfunction are listed in Box 2. Details on dietary and fluid assessment are outlined in Box 3.
Box 2. Patient assessment
Ask the patient about the bowel problem. Consider the following:
The main symptoms and how they bother the patient;
- Normal bowel habit;
- Stool consistency (use the Bristol Stool Chart – see Fig 1);
- Colour and smell of stool and presence of mucus, blood or undigested food;
- Pain on defecation;
- Problems with control – urgency to open bowels with bowel accidents, incontinence of faeces without being aware or flatus incontinence;
- Abdominal pain;
- The need to undertake certain manoeuvres to help empty the bowel, for example, supporting the perineum, digitating into the vagina or manual evacuation;
- Incomplete emptying - not feeling as if they have completely emptied the rectum but cannot empty any more;
- Straining to pass a stool;
- Effects on sexual function;
- Coping strategies – such as toilet mapping(planning journeys based on where toilets are), staying near toilets, using toilet substitutes, appliance use and containment.
Box 3. Assessment of diet and fluids
The patient could complete a food diary before attending for a clinic visit. Assessment includes:
- Fibre content – too much or too little;
- Amount of wheat products – possible intolerance;
- Spicy foods – increase gut motility;
- Supplementary diets – may cause diarrhoea;
- High in fat – may increase gut motility;
- Trigger foods;
- Milk – possible intolerance;
- Coffee, diet drinks, sports drinks, excess alcohol – may increase gut motility, giving a loose stool.
Source: RCN (2008)
Duration and triggers
It is important to identify whether the problem is acute (less than three months) or chronic (more than three months). If there has been a change in the patient’s normal bowel habits lasting for four weeks or longer, ask if this is related to any change in their lifestyle. Questions could cover diet, fluids, medication (including herbal and over-the-counter), personal stresses such as a change in job, recent foreign travel (especially if a patient has diarrhoea) and surgery.
Also consider red-flag symptoms for bowel cancer, such as blood mixed in with stools, an increase in mucus and wind, weight loss without dieting, feeling tired and a family history.
Patients with cognitive problems require careful assessment. For example, if a patient is unable to retain information or change behaviour, there is little point in teaching anal exercises to improve the strength of the pelvic floor muscles as these are unlikely to be carried out. An assessment of cognitive function should include their ability to:
- Understand what is being explained;
- Retain information and learn;
- Change behaviour;
- Carry out instructions at home.
Digital rectal examination should be carried out by a healthcare professional who is competent. This can be used to establish the:
- Strength and movement of the anal muscles – resting tone of the internal anal sphincter, squeeze pressure of the external anal sphincter, length of squeeze and ability to relax on pushing down;
- Presence of faecal matter in the rectum, consistency and amount;
- Anal and rectal sensation;
- Need for rectal medication, manual evacuation;
- Observation of perianal area for the condition of the skin, any abnormalities and faecal soiling.
Using assessment to make a diagnosis
There is a difference between assessment and diagnosis and one is necessary for the other (RCN, 2008). Therefore, once the assessment has been completed, practitioners need to make a clinical decision resulting in a differential diagnosis. Treatment options can then be considered to resolve symptoms.
Treatment options can then be considered to resolve symptoms. This can involve trial and error before treatment that suits the patient is found (Baid, 2006). The patient will need a review assessment to establish whether the treatment plan has been successful.
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Addison, R. (2002) Bowel care needs improving. Nursing Times; 98: 4, 47.
Baid, H. (2006) Differential diagnosis in advanced nursing practice. British Journal of Nursing; 15: 18, 1007–1011.
Department of Health (2001) The Essence of Care: Patient-Focused Benchmarking for Healthcare Practitioners. London: DH.
Kapoor, D. et al (2008) Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic. Colorectal Disease; 10: 2, 118–123.
Klaschik, E. et al (2003) Constipation – modern laxative therapy. Support Care Cancer; 11: 11, 679–685.
Koch, T., Hudson, S. (2000) Older people and laxative use: literature review and pilot study report. Journal of Clinical Nursing; 9: 4, 516–525.
Longstreth, G. et al (2006) Functional bowel disorders. Gastroenterology; 130: 5, 1480–1491.
NICE (2007) Management of Faecal Incontinence in Adults. London: NICE.
Norton, C. (2006) Constipation in older patients: effects on quality of life. British Journal of Nursing; 15: 4, 188–192.
Perry, S. et al (2002) Prevalence of faecal incontinence in adults aged 40 years or more living in the community, Gut; 50: 4, 480–484.
Rockwood, T. et al (2000) Faecal incontinence quality of life scale. Diseases of the Colon & Rectum; 43: 10, 9–16.
RCN (2008)Bowel Care Including Digital Rectal Examination and Digital Removal of Faeces. RCN Guidance for Nurses. London: RCN (currently being reviewed and updated).
Skills for Health (2008) CC01 Assess Bladder and Bowel Dysfunction. Bristol: SfH.
Sultan, A., Thakar, R. (2002) Lower genital tract and anal sphincter trauma. Best Practice and Research in Obstetrics and Gynaecology; 16: 1, 99–116.