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Essential Nursing Care of the Critically Ill Patient 115

bleeding from prophylaxis. Given the risks of VTE for of a protocol improves bowel care. Rectal examination
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critically ill patients, it is clearly important that nurses should be performed within 24 hours of ICU admission
contribute to lowering risks for their patients by knowing and it should also be undertaken if the patient has not
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the range of risk factors for their patients, along with the had their bowels open for three consecutive days. If the
appropriate pharmacological prophylaxis that may be bowels have not been opened during this period, action
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prescribed, how to appropriately implement and manage should be taken. For some patients in whom defecation
the mechanical prophylaxis devices and most impor- is problematic, it may be appropriate to objectively assess
tantly facilitate the early mobilisation of the patient. the quality of faecal stools using a tool such as the Bristol
stool form scale, which uses a 7-point grading system to
BOWEL MANAGEMENT assess stool consistency (see Table 6.10). 97,98
Although bowel care is an essential aspect of nursing care ESSENTIAL BOWEL CARE
in the critical care setting, there is little research evidence
in this area. Good bowel care promotes patient comfort Nursing care is based on managing privacy and embar-
and reduces the risks of further problems such as nausea rassment, increasing exercise where possible, ensuring
and vomiting. The prevention of constipation, which can adequate fibre and fluid in the diet, reducing unnecessary
occur when patients are immobile or have reduced gut use of drugs that cause constipation, and appropriate use
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motility or a poor dietary intake, is important as it may of laxative agents. Where bowel care is concerned, it is
contribute to the exacerbation of other conditions, such always appropriate to first explain to patients what is to
as myocardial infarction, congestive cardiac failure, stroke be done, and to gain their consent if they are conscious.
and head injury. 91,92 Enteral feeding is often cited in the Constant reassurance is important so that patients feel
literature as a cause of diarrhoea, but poor gastric fluid safe and secure in the knowledge that their privacy will
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intake causes constipation, and improved gut motility be maintained to the greatest degree possible. This is
decreases the risk of aspirations. The prevention of con- sometimes difficult when more than one nurse is required
stipation is particularly important for patients with high to position a patient for bowel assessment, defecation or
cervical spinal injuries, as if left untreated it may cause cleansing. However, it is always important to explain to
potentially fatal autonomic dysreflexia. 94 patients why more than one person is necessary and to
reassure them that they will be exposed for the minimum
Bowel care can also be one of the most distressing aspects period necessary.
of nursing care, from a patient’s perspective. Often
patients find bowel care to be awkward and embarrassing, Peristaltic movement of the gut is stimulated by exercise.
which may be particularly intensified when they feel that Although difficult in the intensive care setting, many
they are not in control of their own body. Sensitive patients are awake, and even those who require sedation
nursing care that respects the dignity of the patient is should be sedated with the minimal amount necessary
paramount. for their safety, as this will enable some degree of move-
ment. Promoting movement, especially voluntary move-
BOWEL ASSESSMENT ment, is helpful as it will improve gut motility.
Initial bowel assessment should be undertaken to deter- Diet and Fluids
mine the patient’s usual bowel habits, as less than 10%
of the population have a daily bowel action, and for 1% Diet and fluids are two important considerations in
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of the population less than three times a week is normal. maintaining normal bowel function. Ensuring the appro-
‘Normal’ bowel function should be regarded as at least priate administration of fluid and an adequate dietary
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twice a week. In general, older patients are more suscep- fibre intake helps to prevent constipation. Enteral
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tible to constipation. feeding increases faecal bulk and provides gastric fluid,
Gut function should be assessed at the start of each
nursing shift (see Box 6.2). Several authors 91,92,96 have
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developed bowel care protocols for intensive care patients.
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The results of the McKenna et al. study suggest that use
TABLE 6.10 Bristol stool form scale
Grade Description
0 No bowel movement
1 Separate hard lumps; like nuts; hard to pass
BOX 6.2 Assessment of gut function
2 Sausage-shaped but lumpy
● Observation of nasogastric aspirate volume 3 Like a sausage but with cracks on the surface
● Visual inspection and palpation of abdomen, noting any
tenderness, pain or distension 4 Like a sausage or snake but smooth and soft
● Recording the frequency, nature and quantity of bowel 5 Soft blobs with clearcut edges; easily passed
actions 6 Fluffy pieces with ragged edges; a mushy stool
● The presence or absence of bowels sounds
7 Watery; no solid pieces; entirely liquid