Bowel Management Program After Spinal Cord Injury

GENERAL INFORMATION:

What is a bowel management program? Having a spinal cord injury (SCI) can interrupt the nerve pathways from your brain to your gastrointestinal (gas-tro-in-TES-tih-null) or "GI" system. You may not be able to control bowel functions after a spinal cord injury. This condition is called neurogenic (ner-o-JEN-ik) bowel. Ask caregivers for more information about neurogenic bowel.

What should I do while on a bowel management program? Most people with a SCI can learn how to control their bowel function. Bowel management programs help you eliminate (get rid of) enough BM at regular planned times. This will help prevent or decreases BM accidents. A bowel management program is made up of four parts:

• 1. Activity: Activity is very important for everyone. It helps you to have BM's regularly. After a spinal cord injury, you will need to make a point of moving often. Change positions often from lying to sitting to standing, if possible. Have your joints moved through their full range of motion several times a day. These activities help your bowels move naturally.
  
  
  • If possible, sit up to have your BM's. This will allow gravity to help pull the BM down the bowel. Use a padded toilet stool if you have to sit more than 30 minutes to help prevent pressure sores. Make sure you do not sit on a toilet or commode chair that has seams, or cracked or broken plastic. This can cause skin problems. Make sure you use safety straps where needed.
    
    
  • You may want to try having your feet placed on a footstool so you can push down better during the BM.
  
  
• 2. Diet and liquids: Food and liquids play an important role in your bowel program. When you eat also is important. Eat about 30 minutes before you begin your bowel care program. This will stimulate you to have a BM because of the stomach's reflexes.
  
  
  • Drink enough liquids: Not drinking enough fluid can make you constipated. Drink eight to 12 (eight ounce) glasses of liquid each day. Follow your caregiver's advice if you must limit the amount of liquid you drink for a bladder management program. Good liquids to drink are water, juices, and milk. Avoid drinking liquids with caffeine and alcohol. caffeine and alcohol may cause dehydration (not enough fluid in the body).
    
    
  • Eat a variety of healthy foods: Eat different foods from all the food groups every day. Some foods do not affect BM's, such as meat, fish, cooked vegetables, and fats. Other foods may make your BM's harder or softer. If you feel constipated, eat more foods that soften BM's and less of the foods that harden BM's. If your BM's are too soft, avoid foods that soften BM's and eat more foods that harden BM's.
    
    
    • Foods that harden BM's include applesauce, milk and dairy foods, white breads and refined cereals and cookies, white rice, and creamed soups and sauces.
      
      
    • Foods that soften BM's include fresh, raw (uncooked) fruits and vegetables, whole grain breads, cereals and rices, beans, coffee, and dark chocolate.
      
      
    • Many vegetables and fruits cause gas. Some gas is normal, but too much can be unpleasant. You may want to try not eating a specific food to see if it is causing you to have gas. Eating slowly with your mouth closed may help to decrease gas. Talking while chewing, and gulping your food makes you swallow air. This may also cause too much gas.
  
  
• 3. Medicines: Many medicines cause constipation. The larger the dose you take of these medicines, the more problems you may have with constipation. Medicines that may cause constipation include some high blood pressure medicines, pain killers and sedative medicine, and iron supplements. Medicine used to treat depression, stomach pain, and bladder spasms may also cause constipation. Tell your caregivers if you are having problems with constipation so they can work with you to decrease the problem.
  
  
• 4. Routine bowel care: A bowel care program helps you completely empty your bowel at a specific time. The program should take no more than one hour at a time. It should be done every day, every two days, or every three days. You should do your bowel care program at the same time each day so your body develops a habit. Eat food or drink liquids about 30 minutes before you start to stimulate your bowel to have a BM.

How should I do bowel care if I have spastic bowel? With spastic bowel, your bowel functions normally to form soft BM's and your sphincter (SFINGK-ter) remains tight. Remember to wash your hands at the beginning, after each step of the process, and at the end. Start by emptying your bladder.

• Step One: Insert the suppository. Some suppositories lubricate (moisten) the rectum to help the stool come out easier. Other types soften the stool and also stimulate the bowel to have a BM. Caregivers will help you decide if you need a suppository, and which kind to use. Insert a suppository lubricated with a clear jelly-like lotion after removing any stool that is in the way. Put in the supository. Using the finger of one gloved hand, or a suppository inserter, place it as high into the rectum as possible. The suppository should rest against the side of the rectum, not in the middle of stool. Slowly take your finger or the suppository inserter out, making sure that the suppository does not come out.
  
  
• Step Two: Move into position. Sit up on the commode or commode chair, or in your wheelchair ready to move to the commode. Sitting up lets gravity help you have a BM.
  
  
• Step Three: Massage your abdomen. Massage (gently rub) your abdomen (belly) for five to 10 minutes. Place the palm of your hand on the lower right part of your abdomen. Press in and move up to your ribs, straight across to the left side of your abdomen. Then keep pressing in as you move your hand down the left side of your abdomen. Massaging in this method, massages the length of the colon toward your rectum. Repeat this 10 times, waiting about 30 seconds in between.
  
  
• Step Four: Wait for the suppository to work. Wait about 10 to 15 minutes for the BM to start.
  
  
• Step Five: Stimulate your bowel. If you have not had a BM in 15 minutes, perform digital (DIJ-it-l) (finger) stimulation. Put a well-lubricated, gloved finger into your rectum about two to three inches inside your anus. The goal is to massage the inner sphincter (a ring of muscle inside the anus). To do this, point your finger toward your belly button and move it in a circle around the walls of the rectum. Keep moving your finger in a circle staying in contact with the rectal wall for about 20 seconds. Do not continue for longer than 1 minute. Repeat this every 5 to 10 minutes until you have a BM.
  
  
• Step Six: Completely empty your bowel. Perform digital stimulation two more times after the BM, waiting 5 to 10 minutes in between. This makes sure your bowel is as empty as possible.

How should I do bowel care if I have flaccid (limp) bowel? With flaccid bowel, the goal is to have firm, formed BM's that you can hold between bowel care sessions. The BM's should be soft enough so that you can easily pass them manually (without help). You should perform your bowel program once or twice a day to prevent accidents. Remember to wash your hands at the beginning, after each step of the process, and at the end. Start by emptying your bladder.

• Step One: Move into position. Sit up on the commode or commode chair, or in your wheelchair ready to move to the commode. Sitting up lets gravity help you have a BM. You may also lie on your side.
  
  
• Step Two: Do manual extraction. Put on gloves and lubricate one or two fingers very well. Gently insert the fingers into your rectum and scoop out the stool.
  
  
• Step Three: Stimulate your bowel. Perform digital stimulation to help your anal sphincter completely relax. Put a well-lubricated, gloved finger into your rectum about two to three inches inside your anus. The goal is to massage the inner sphincter (a ring of muscle inside the anus). To do this, point your finger toward your belly button and move it in a circle around the walls of the rectum. Keep moving your finger in a circle staying in contact with the rectal wall for about 20 seconds. Do not continue for longer than one minute.
  
  
• Step Four: Do the Valsalva (val-SAL-vah) maneuver (mah-NEW-ver). This procedure is good if you have control over your abdominal muscles by helping to push out the BM. Take a deep breath and bear down but do not let your air out. Try to tighten your stomach muscles at the same time. Doing valsalva maneuvers increases the pressure around the bowel which pushes stool out. Do it for 30 seconds at a time until you have finished having the BM.
  
  
• Step Five: Move around. Lift yourself and bend forward and sideways if your upper body is strong enough. Doing this with valsalva maneuvers helps change the position of the bowel. This helps push out the BM.
  
  
• Step Six: Wait to have a BM. Wait about 10-15 minutes for the BM to start. If you have not had a BM within 15 minutes, insert a suppository.
  
  
• Step Seven: Completely empty your bowel. Perform digital stimulation two more times after the BM, waiting five to 10 minutes in between. This makes sure your bowel is as empty as possible.

Why should I keep a bowel care record? Keeping a bowel care record helps you and your caregivers know whether your bowel program is working. Write down the following information after each bowel care session:

• Date: Write down the date.
  
  
• Start time and end time: Writing down what time you started and finished, helps you and your caregivers know how well things are going. Caregivers can help you learn ways to speed up the process. They also can show you where to slow down if needed to give your bowel time to do its work.
  
  
• Position: Write down the position (sitting or lying) that you were in while doing bowel care.
  
  
• Stimulation: Write down any methods used while doing bowel care, such as using a suppository, or digital stimulation.
  
  
• Assistive actions: Write down other methods used to empty your bowel. This may include abdominal massage, or the valsalva maneuver. Note how many times you used each method.
  
  
• Time of the BM: This information helps caregivers know how successful your bowel care program is.
  
  
• Describe your BM: This can help caregivers know if there are any problems with your bowels, like constipation or bleeding. Caregivers may be able to discover bowel problems by how your BM looks.
  
  
• Comments: Write down any other things you notice or if you have problems, like cramps, muscle spasms, or accidents. Note whether there are any skin problems from your bowel care equipment.

What should I do if I have an accident when I am in a public place or around other people? Having an accident is embarrassing for you and for other people but it is normal. Do not sit there and try to ignore it. If you can, leave and go to a bathroom as soon as possible. This will help people around you feel more comfortable, as well as helping to prevent skin breakdown. It is also important to go to the bathroom right away because trying to hold BM's can cause autonomic dysreflexia.

Where can I go for support?

• Having a spinal cord injury is life changing for you and your family. Accepting that you have a spinal cord injury is hard. You and those close to you may feel angry, sad, or frightened. These feelings are normal. Talk to your caregivers, family, or friends about your feelings. Let them help you. Encourage those close to you to talk to your caregiver about how things are at home. Your caregiver can help your family better understand how to support a person with a spinal cord injury.
  
  
• You may want to join a support group. This is a group of people who also have spinal cord injuries. Ask your caregiver for the names and numbers of support groups in your town. You can contact one of the following national organizations for more information:
  • Paralyzed Veterans of America
    801 Eighteenth Street NW
    Washington, DC, 20006
    Phone: 1-800-424-8200
    Web Address: www.pva.org
    
  • National Spinal Cord Injury Association
    6701 Democracy Blvd, Ste 300-9
    Bethesda, MD 20817
    Phone: 1-800-962-9629
    Web Address: www.spinalcord.org
    
  • American Spinal Cord Association
    2020 Peachtree Road, NW
    Atlanta, Georgia, 30309-1402
    Phone: 1-404-355-9772
    Web Address: www.asia-spinalinjury.org
    

Call ____ if: You have:

• Abdominal (belly) pain or a distended (swollen) abdomen that is worse than normal and is not better after performing bowel care.
  
  
• Bleeding from the rectum.
  
  
• A temperature over ____.
  
  
• Vomiting (throwing up) or diarrhea (loose stools) for two or more days.

Seek care immediately if: You have symptoms of autonomic dysreflexia that are not relieved by your bowel program or emptying your bladder, such as:

• A sudden increase in blood pressure.
  
  
• Blurred vision or seeing spots.
  
  
• Cold, dry, skin with goose bumps below your SCI.
  
  
• Hot, sweating, flushed (red) skin above your SCI.
  
  
• Sudden throbbing headache.

CARE AGREEMENT:

You have the right to help plan your care. To help with this plan, you must learn about your health condition and how it may be treated. You can then discuss treatment options with your caregivers. Work with them to decide what care may be used to treat you. You always have the right to refuse treatment.

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