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BACKGROUND Oral care is one of the fundamental nursing care procedures used to decrease oral colonization, dental plaque, respiratory infections, and patient stay and cost. AIMS This study aimed to identify intensive care unit (ICU) nurses' self-assessment of oral care frequency, skill competency, documentation, oral care tools, and obstacles to oral care quality. In addition, it proposed exploring associations between nurses' attitudes about the importance of oral care and the priority of other interventions. STUDY DESIGN AND SETTING A cross-sectional descriptive study was conducted in two ICUs (trauma and general) in the main teaching hospital in Upper Egypt. Of 105 nurses selected using convenience sampling, 91 completed the questionnaire. RESULTS About 60.4% of ICU nurses did not attend any oral care training programme, 40.7% reported performing oral care four times per shift in intubated patients, 62.6% reported that their skills needed improvement, 37.4% saw themselves as competent, and 86.8% documented oral care in patients' records. Significant positive correlations were found, indicating that nurses' attitudes towards the importance of oral care showed the same tendency as the priority given to other interventions, such as eye care, bowel care, documentation, hygiene, catheters, feeding, and wound care (correlation coefficient [r] = 0.290, 0.511, 0.333, 0.425, 0.431, 0.345, and 0.337, respectively). Furthermore, a toothbrush (84.6%) was often used, while chlorhexidine was not used (90.1%). The major obstacles to the provision of oral care as perceived by the nurses were the fear of aspiration and life-threatening interventions (95.6%), inadequate nurse-patient ratios (94.5%), irregular competency evaluations (92.3%), unavailability of oral care guidelines (92.3%), and shortage of time (84.6%). CONCLUSION The participating nurses were mindful of the importance and priority of oral care. Many of them did not attend oral care training programmes and considered that their skills needed improvement. Moreover, ICU nurses reported many obstacles hindering oral care quality. RELEVANCE TO CLINICAL PRACTICE This research identifies the importance of developing in-service oral care training programmes to improve ICU nurses' skill competency. High-quality oral care can be provided by focusing on and overcoming obstacles that hinder nurses' oral care practice.

Background: Bowel dysfunction, including constipation and fecal incontinence, is prevalent in individuals with multiple sclerosis (MS), adversely affecting quality of life and increasing caregiver burden. How health care professionals (HCPs) identify, assess, and manage people with MS with bowel dysfunction is understudied. This study explored how HCPs think about, assess, and manage bowel dysfunction in individuals with MS. Methods: Semistructured interviews were conducted with 18 HCPs from different professional disciplines and clinical specialties recruited from UK National Health Service primary, secondary, and tertiary care services using purposive and chain referral sampling through professional networks. One participant worked for a bladder and bowel charity. Data were analyzed using thematic analysis. Results: Views differed regarding responsibilities for providing bowel care. Participants thought individuals with MS should notify HCPs of bowel symptoms and take responsibility for self-management where possible, with family caregivers required to help with bowel care. Although people with MS were often referred to bladder and bowel specialists when a crisis point was reached, earlier referral was called for by these HCPs. There were variations in assessment processes, treatment options offered, and service provision. Participants thought HCPs needed more education on bowel dysfunction, bowel care should take a high priority, and evidence-based clinical guidelines and referral pathways would improve service delivery. Conclusions: The HCPs caring for individuals with MS see many with bowel dysfunction, and there is variation in care and service provision; HCPs require more education, evidence-based clinical guidelines, and referral pathways to improve case finding, assessment, and management of these symptoms for individuals with MS.

Using their experience of effectively pitching for better bowel care pathways, the Bowel Interest Group provide comprehensive, step-by-step guidance on how to make a sound business case for creating or improving services in the NHS.

Background:Following patient preferences at the end of life should improve outcomes of care, yet patient preferences regarding bladder and bowel care are not often accommodated, as they are not well known in the literature.Aims:This scoping review sought to identify bladder and bowel care preferences of patients at the end of life in published literature.Methods:Papers published in or after 1997 (in English) that focused on adult preferences for bladder and bowel care at the end of life were included.Findings:Scant literature exists on preferences for bladder and bowel care for adult patients at end of life. Further investigation is warranted to arrive at a better understanding of preferences regarding bladder and bowel symptom management.Conclusions:Future research should explore if prioritising the symptoms caused by incontinence, among the many symptoms experienced at the end of life, could be achieved through careful questioning and development of a standardised tool focused on improving patient care and incorporating patient preferences for care.

Background Spinal cord injury (SCI) has a significant impact on the quality of life (QoL) of affected patients. The aim of this review was to determine whether colostomy formation improves QoL in patients with SCI. Methods The Cochrane Register, MEDLINE, Embase and CINAHL were searched using medical subject headings. The search was extended to the reference lists of identified studies, ClinicalTrials.gov and the WHO International Clinical Trials Registry. All clinical trials that included spinal injury and QoL, time spent on bowel care, and patient satisfaction with stoma were assessed. Results A total of 15 studies were found (including 488 patients with a stoma), of which 13 were retrospective cross‐sectional studies and two were case–control studies, one of which was prospective research. Nine of 11 studies focusing on QoL reported that patients' QoL was improved by the stoma, whereas the remaining two studies found no difference. Time spent on bowel care was significantly reduced in all 13 studies that considered this outcome, with patients reducing the average time spent on bowel care from more than 1 h to less than 15 min per day. All 12 studies assessing patient satisfaction with their stoma reported high patient satisfaction. Conclusion Stoma formation improves QoL, reduces time spent on bowel care, and increases independence. Stoma is an option that could be discussed and offered to patients with spinal cord injury., In this systematic review to determine whether colostomy formation improved the quality of life (QoL) in patients with spinal cord injury, outcomes assessed were QoL, time spent on bowel care, and patient satisfaction with the stoma. A total of 15 studies were included; colostomy formation improved QoL and time spent on bowel care, and more than 90 per cent of patients were satisfied with having a stoma. Stoma and spinal cord injury

Background Although codes of conduct, guidelines and standards call for healthcare practitioners to protect patients’ dignity, there are widespread concerns about a lack of attention to the dignity of older people who need assistance with toileting, incontinence or bladder or bowel care in health or social care settings that provide long-term care. Incontinence and care dependence threatens patient dignity. The aim of this research was to explore, describe and explain the concept of dignity as it relates to continence care for older people requiring long-term care. Methods The first four steps of Rodgers evolutionary method of concept analysis were followed. First, a comprehensive and systematic search of databases and key guidelines about continence care was undertaken to identify empirical research about dignity and continence care in older people in facilities that provide permanent residential or inpatient care of older people for day-to-day living. Data were extracted on the authors, date, sample, country of origin, and key definitions, attributes, contexts and consequences from each included record. Findings were inductively analysed and grouped according to whether they were the key attributes and antecedents of dignity in relation to continence care or the consequences of undignified continence care. Results Of 625 articles identified, 18 were included in the final analysis. Fifty individual attributes were identified that were categorised in 6 domains (respect, empathy, trust, privacy, autonomy and communication). A further 15 were identified that related to the environment (6 physical and 9 social). Key consequences of undignified continence care were also identified and categorised into 3 levels of impact (resident/family member, staff or organisation). Conclusions This research resulted in a conceptual understanding of dignity that can be used as a value or guiding principle in an ethic of care for older people who need assistance with toileting, incontinence or bladder or bowel care in long-term care settings.

Clinical trial. Spinal cord injury (SCI) impacts autonomic function and bowel management. Bowel care is a potential trigger for autonomic dysreflexia (AD; paroxysmal hypertension elicited by sensory stimuli below the level of lesion). AD can be life threatening so strategies to minimise AD are prioritised after SCI. Lidocaine lubricant is recommended during bowel care with the rationale to minimise the sensory stimulus, reducing AD. The objective of this study was to assess whether lidocaine lubricant (Xylocaine 2%) ameliorates AD during at-home bowel care compared with standard lubricant (placebo). Community. Participants (n = 13; age 44.0 ± 3.3 years) with high-level SCI (C3-T4) performed their normal at-home bowel care on two days, each time using a different lubricant, with continuous non-invasive cardiovascular monitoring. Injury to spinal autonomic (sympathetic) nerves was determined from low-frequency systolic arterial pressure (LF SAP) variability. Participants displayed reduced autonomic function (LF SAP 3.02 ± 0.84 mmHg2), suggesting impaired autonomic control. Bowel care duration was increased with lidocaine (79.1 ± 10.0 min) compared to placebo (57.7 ± 6.3 min; p = 0.018). All participants experienced AD on both days, but maximum SAP was higher with lidocaine (214.3 ± 10.5 mmHg) than placebo (196.7 ± 10.0 mmHg; p = 0.046). Overall, SAP was higher for longer with lidocaine (6.5 × 105 ± 0.9 × 105 mmHg • beat) than placebo (4.4 × 105 ± 0.6 × 105 mmHg • beat; p = 0.018) indicating a higher burden of AD. Heart rate and rhythm disturbances were increased during AD, particularly with lidocaine use. At-home bowel care was a potent trigger for AD. Our findings contradict recommendations for lidocaine use during bowel care, suggesting that anaesthetic lubricants impair reflex bowel emptying, resulting in longer care routines with an increased burden of AD.

Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.

AIM: The formation of a diverting stoma of the bowel in patients with spinal cord injury (SCI) is a useful option in managing problems associated with prolonged bowel care, pressure ulcers and neurogenic bowel. This descriptive study examines surgical outcomes and the effect on an individual's health-related quality of life (HrQoL) in this complex group of patients. METHODS: Data were retrospectively collected in all patients with SCI who underwent a diverting stoma at Prince of Wales Hospital, Sydney, between January 2013 and January 2018 via a self-report questionnaire developed specifically for the study. RESULTS: Forty-three individuals were identified of whom 26 responded. 73% were men with a mean age of 45 years. The reasons for stoma formation included sacral pressure ulcer (50%), prolonged bowel care (35%), faecal incontinence (19%), constipation (8%), autonomic dysreflexia (8%), carer difficulties (8%) and haemorrhoids (4%). 76% of patients reported an improvement in HrQoL with 72% scoring their satisfaction with a stoma ≥ 8/10. CONCLUSION: While stoma formation is often seen as a treatment of last resort, our study has shown that it is an effective management option for a number of conditions post-SCI. It can improve HrQoL and has a high level of satisfaction amongst patients. Ideally, patients who could potentially benefit from a stoma should be identified early and receive appropriate education and counselling to help facilitate informed and timely decision-making and reduce adverse bowel related impact on quality of life and adjustment post-SCI.

Objective: This prospective study examined the defecation enhancement effects in post-lumbar laminectomy patients who received Thai traditional medicine of abdominal massage (TTMAM) in combination with standard nursing care, compared with patients receiving only standard nursing care. Methods: This prospective, randomized, controlled trial was conducted at Siriraj Hospital between 2011 and 2015. Eighty-eight patients with spinal stenosis scheduled for lumbar laminectomy with or without fusion were enrolled. The patients were randomly assigned to two groups: the first group underwent standard nursing care combined with TTMAM (the TTMAM group), and the second group underwent standard nursing care (the non-TTMAM group). The clinical outcomes regarding the first defecation within 3 days after surgery, abdominal distension, and patient satisfaction with defecation care were evaluated. Results: When comparing the first defecation within 3 days after surgery, no significant differences were found in the number of patients between the two groups. The number of the patients who had their first defecation within 3 days after surgery was higher in the TTMAM group (46.5%) than the non-TTMAM group (27.3%). There was significantly less abdominal distension on the third day after surgery in the TTMAM group than in the non-TTMAM group. Moreover, the mean score of patient satisfaction of the TTMAM group was higher than that of the non-TTMAM group. Conclusion: Thai traditional medicine of abdominal massage tends to help defecation in post-lumbar laminectomy patients as it relieves abdominal distension and increases satisfaction with defecation care. Therefore, the use of TTMAM with other bowel care methods could provide additional benefit for lumbar laminectomy patients.

Context: It is often a challenge to counsel parents with children operated for spina bifida aperta in developing countries. Data regarding the efficacy of simple measures and preventive are scarce. Aims: The aim of this study is to study such children for the incidence, prevalence of bowel bladder dysfunction, and the quality of life (QOL) in children who are involved with a multidisciplinary team in India. Materials and Methods: All children with spina bifida occulta were followed – QOL questionnaires (PIN Q, modified Barthels activities of daily living , and the visual analog score [VAS]) were used. Interventions, such as clean intermittent catheterization (CIC), bowel enemas, and surgical procedures, were studied. Results: A total of 68 children were assessed. Twenty-nine of these children over five were evaluated with QOL scores. The prevalence of incontinence of bowel and bladder was studied. The primary outcomes included the QOL scores, and the various surgical options help bowel and bladder management. Hydronephrosis in 17.95% of children

Background: Colostomy formation can solve complications of bowel management following spinal cord injury (SCI). Newly injured patients at this spinal unit have chosen colostomy as a preferred option for bowel management. Objectives: To discover the reasons patients choose colostomy formation early following SCI and make comparison with those choosing it later, and to establish whether early colostomy is safe and advisable. Methods: Medical and nursing records of patients with SCI who chose to have a colostomy during the period 2005–2016 were examined retrospectively. Data were gathered concerning reasons for choosing a colostomy, early and later complications, the need for further surgery, and independence with bowel care before and after surgery. Patients were divided into two groups: those who chose a colostomy “early” during inpatient rehabilitation and those who chose it “later” as is traditional. Results: Reasons for choosing colostomy differed. Reducing reliance on caregiver and independence were of more importance to the early group; the later group chose colostomy to solve bowel care problems. Early complication rates in both groups were low. Longer term complications were higher in the early group, with the most common complication being rectal discharge. Parastomal hernia rates were low in both groups, as was the need for further surgery. Colostomy formation led to 20.8% of all patients gaining independence with bowel care. Conclusion: This study found colostomy to be a safe and effective option when performed early after SCI and demonstrates colostomy can be a means of gaining independence and making bowel care easier and more acceptable to the newly injured patient.

Objectives: To identify and classify tools for assessing the influence of neurogenic bowel dysfunction (NBD) on quality of life (QoL) after spinal cord injury (SCI). Methods: In this systematic review, MEDLINE/PubMed, CINAHL, and PsycInfo were searched to identify studies assessing the influence of NBD on QoL (or related construct) after SCI. Two independent reviewers screened titles and abstracts, and both reviewers classified tools as subjective or objective according to Dijkers' theoretical QoL framework. Results: Seventy-two studies were identified, and 35 studies met the inclusion criteria. Five objective measures assessed the influence of NBD on QoL, which were validated for use in SCI, but no measure was condition-specific to NBD. Eight measures were classified as subjective tools; two had an established reliability and validity for SCI while six had some psychometric evidence for use in the SCI population. Five subjective measures (NBD score, Burwood QoL Questionnaire, Impediments to Community Integration [ICI] Scale, SCI-QoL Bowel Management Difficulties, and Survey of Neurogenic Bowel Characteristics) were developed specifically for SCI. The NBD score showed sensitivity to the influence of NBD on QoL in experimental trials. Conclusion: Thirteen tools assessed the influence of NBD on QoL in SCI. Although not developed specifically for SCI, the Health Utility Index (HUI-III) was the only tool identified that provided data on “QoL as utility” on the impact of NBD. The validated NBD score was the only condition-specific tool to assess QoL as “subjective well-being.” Further validation of existing tools could help to inform practice and policy related to resource allocation for bowel care post SCI.

The Peristeen transanal irrigation system is intended to allow people with bowel dysfunction to flush out the lower part of the bowel as part of their bowel management strategy. Peristeen was the subject of an evaluation by the National Institute for Health and Care Excellence, through its Medical Technologies Evaluation Programme, for the management of bowel dysfunction. The company, Coloplast, submitted a case for adoption of the technology, claiming that the technology improves the severity of chronic constipation or faecal incontinence and improves quality of life for people with bowel dysfunction. Other claimed benefits included reduced frequency of UTIs, stoma surgery and hospitalisation rates, as well as reduced costs. The submission was critiqued by Cedar. The clinical evidence assessed included one randomised controlled trial, and 12 observational studies for adults and 11 studies for children. Although there are limitations in the evidence, the assessed studies show some improvement in outcomes for patients who choose to continue using Peristeen. The committee heard from patient experts that Peristeen had improved their lives and allowed them increased independence. The submitted economic evidence had numerous flaws, however following Cedar’s changes to the model, and additional sensitivity analysis, the use of Peristeen was judged unlikely to be cost incurring compared with standard bowel care. The Peristeen transanal irrigation system received a positive recommendation in Medical Technologies Guidance 36.

Aims and objectives To examine the nature of problems experienced by people with spinal cord injury (SCI) when accessing help to maintain recommended bowel regimes while hospitalised outside a specialist spinal injury service. Background Bowel dysfunction is one particularly undesirable aspect of life with a SCI, with constipation and incontinence common. Design Descriptive qualitative. Methods Accounts of problems encountered in hospitals in New South Wales Australia collected during interviews with 11 people living with SCI and 12 responses provided by spinal clinicians via an online survey were subjected to thematic analysis. The COREQ guidelines were followed for reporting. Results There were similarities across data collected from both sources. Individuals with SCI described instances where their bowel care needs did not fit with the pace and processes in acute hospitals. The clinician data pointed to a failure of healthcare professionals to assist people with SCI to maintain bowel care regimes recommended by specialist spinal services. Both groups described times when bowel care received was unreliable and fragmented, along with reports of staff who were unwilling and/or unable to provide the assistance required. Many and varied physical and psychosocial repercussions for individuals were associated with these system failures. In some instances, rather than restoring health, being admitted to hospital represented a significant health risk. Conclusion A failure of hospital systems to meet the bowel care needs of people with SCI when hospitalised outside a specialist spinal unit was identified. System and individual factors contributed to these problems, hence addressing them requires both system and individual responses. Relevance to clinical practice If this problem is left unaddressed, the health and quality of life of people with SCI will continue to be compromised. Nursing scope of practice needs to be clarified and communicated to nurses outside specialist spinal injury units in relation to their role in maintaining bowel care regimes recommended for their patients by spinal specialists, and nurses need to ensure they possess the skills required. To allocate the time needed to provide this care, individual nurses need the support of the whole nursing team, including managers who are prepared to arrange additional staff when needed.

Neurogenic bowel dysfunction (NBD) is a common problem for people with spinal cord injury (SCI) and multiple sclerosis (MS), which seriously impacts quality of life. Pharmacological management is an important component of conservative bowel management. The objective of this study was to first assemble a list of pharmacological agents (medications and medicated suppositories) used in current practice. Second, we systematically examined the current literature on pharmacological agents to manage neurogenic bowel dysfunction of individuals specifically with SCI or MS. We searched Medline, EMBASE and CINAHL databases up to June 2020. We used the GRADE System to provide a systematic approach for evaluating the evidence. Twenty-eight studies were included in the review. We found a stark discrepancy between the large number of agents currently prescribed and a very limited amount of literature. While there was a small amount of literature in SCI, there was little to no literature available for MS. There was low-quality evidence supporting rectal medications, which are a key component of conservative bowel care in SCI. Based on the findings of the literature and the clinical experience of the authors, we have provided clinical insights on proposed treatments and medications in the form of three case study examples on patients with SCI or MS.

Background: Most patients with a spinal cord injury (SCI) suffer from neurogenic bowel dysfunction (NBD). In spite of well-established treatment algorithms, NBD is often insufficiently managed. The Monitoring Efficacy of Neurogenic bowel dysfunction Treatment On Response (MENTOR) has been validated in a hospital setting as a tool to support clinical decision making in individual patients. The objective of the present study was to describe clinical decisions recommended by the MENTOR (either &ldquo, monitor&rdquo, &ldquo, discuss&rdquo, or &ldquo, act&rdquo, ) and the use of the tool to monitor NBD in a non-hospital setting. Methods: A questionnaire describing background data, the MENTOR, ability to work and participation in various social activities was sent by mail to all members of The Danish Paraplegic Association. Results: Among 1316 members, 716 (54%) responded, 429 men (61%) and 278 women (39%), aged 18 to 92 (median 61) years. Based on MENTOR, the recommended clinical decision is to monitor treatment of NBD in 281 (44%), discuss change in treatment in 175 (27%) and act/change treatment in 181 (28%). A recommendation to discuss or change treatment was associated with increasing age of the respondent (p = 0.016) and with impaired ability to work or participate in social activities (p &lt, 0.0001). Conclusion: A surprisingly high proportion of persons with SCI have an unmet need for improved bowel care. The MENTOR holds promise as a tool for evaluation of treatment of NBD in a non-hospital setting.

Neurogenic bowel dysfunction (NBD) results from a constellation of interacting impairments that prevent the voluntary control, process and personal management of defecation. NBD results in colonic dysmotility and pelvic floor defecation disorder and directly contributes to symptoms of constipation, fecal incontinence, and abdominal complaints. Taken together, the severity of these often preventable sequelae cause serious medical problems, retract severely from quality of life and increase the expense of care. This chapter presents pertinent anatomy, contemporary physiology, and pathophysiological processes to prepare the clinician to understand NBD issues, and recognize impairments as targets for patient-centered multiple intervention rehabilitation designs. Informed history taking and guided physical examination reveal patterns of impairment such as reflexic upper motor neuron versus areflexic!lower motor neuron NBD, and limitations related to the primary disease processes. Problem and goal-based care plans are assembled as the Bowel Program which is the comprehensive treatment and rehabilitation system including essential components: diet, fluids, physical activity, medications, scheduled Bowel Care, and rectal stimulation. Bowel Care is the process of assisted defecation which includes one or more of the following components: positioning, assistive techniques, rectal stimulation, and adaptive equipment. Innovative and validated surgical procedures accomplish improvements in independence, reductions in care time, and prevention of incontinence. Research and expert opinion have provided evidence-based best practices outlined in randomized studies, very recently updated clinical practice guidelines and patient education media. This chapter meets the education goals required to prepare clinicians to establish interdisciplinary programs of intervention to detect impairments, educate to implement effective treatments and achieve unique life participation outcomes for each patient and family.

Introduction Acute Colonic Pseudo-Obstruction (ACPO) is a rare clinical condition characterized by gross dilation of the large bowel in the absence of an obstruction. It presents a particularly complex challenge in diagnosis and management in the context of burn trauma. We followed five burn patients who developed ACPO that did not respond to conservative treatments. These patients ultimately required surgical intervention to resolve their ACPO. Through our study, we propose that traditional management may not be successful in fully treating ACPO in burn patients without recurrence and that complete resolution necessitates a more aggressive management course, often in the form of surgical intervention. Methods We studied the clinical course of all burn patients who developed ACPO in the past 2 years at our burn center. Using Electronic Health Records, we collected patient demographic data, percent total burn surface area (%TBSA), hospital length of stay, cecal diameter, bowel regimen for catharsis, and vital sign measurements. Abdominal CT scans and X-rays were used to monitor the progression of cecal diameter. Results We have noted that burn patients who are at a high risk of developing ACPO tend to either be obese, have large TBSA burns (>20%), or have a combination of both. Furthermore, patients who had a greater percentage of 3rd degree burns had worse outcomes. All patients received acetylcholinesterase inhibitors (AChEi’s), but ultimately underwent some manner of further intervention for complete resolution of ACPO. Two patients were treated solely with decompression: one via NGT suction, the other via colonoscope. Three patients received surgical intervention through hemicolectomy, subtotal colectomy, and cecostomy. The former two subsequently expired, one due to direct ACPO complications; the latter three survived and remain well today. Conclusions ACPO is a rare but serious complication in burn patients that may easily be missed by the diagnosing clinician. In the treatment of ACPO in burn patients, one should consider a more aggressive approach, as traditional medical therapy may not be enough to resolve the original distention or prevent a recurrence. In our review of five burn patients that subsequently developed ACPO, surgical intervention was universally the mechanism by which definitive resolution of the condition was achieved.

Aims: To identify nurses’ perceived factors of reluctance to implement the bowel protocol in the ICUs. Background: However, Bowel regimen protocol of patients in the intensive care unit is safe, feasible, and beneficial, its’ implementation as part of routine nursing clinical care can be challenging. Study design: Descriptive cross-sectional design. Methods: A cross-sectional survey of 64 nurses who were working in intensive care units and meet the inclusion criteria was conducted between April 2017 and February 2018. The survey instrument was a semi-structure interview questionnaire developed by the researchers based on the related literature. Results: The mean age of studied nurses was 29.12± 6.41. The most frequently nurses’ perceived factors of reluctance to deliver bowel regimen were the busy shift (93.8%), limited staff & lack of supervision (92.2 %), the low priority of bowel care (90.6%) when considered against other demands of the highly technical intensive care units, unclear order from the doctors (89.06%)., forgetfulness and lack of education and awareness(92.2 %). Conclusion: This study provides an understanding of the perceived factors of reluctance to deliver bowel regimen for critically ill patients. Implications for Nursing Management: Nurse Managers could deal with factors of reluctance to deliver bowel regimen protocol in the ICUs and develop new strategies to overcome these factors Keywords: critical care; intensive care; bowel care DOI: 10.7176/JHMN/73-10 Publication date: April 30 th 2020

Introduction Previous research in children with Hirschsprung's disease (HD) and Down's syndrome (DS) has focused on colorectal outcomes. We set out to review urinary outcomes in this patient group. Materials and Methods The medical records of all patients aged five years and older with HD were reviewed, and patients and caregivers filled out the Vancouver Symptom Score at intake, which is designed and validated to diagnose dysfunctional elimination syndrome. Results A total of 104 patients with HD were included in this study. Of these, 16 (15%) patients had DS. There were no significant differences in the prevalence of enterocolitis or colorectal symptoms between patients with or without DS. Five of 88 (6%) patients without DS and 7 of 16 (44%) (p = 0.00001) with DS reported having urinary accidents. Patients with HD and DS scored higher on the Vancouver score (9 vs. 17.5; p = 0.007), indicating more severe urinary symptoms. Patients who also reported fecal accidents scored significantly higher on the Vancouver (12 vs. 9; n = 61; p = 0.016), indicating more problems. Conclusion Patients with DS appear to be a unique subset of HD patients who have a higher prevalence of urinary symptoms after surgery. In the postoperative care of patients with HD and DS, a strong focus should be placed on postoperative urinary care in addition to their bowel care. This could significantly ease care and contribute to the quality of life of the parents and the patient.

Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high-level lesions, bowel management is a common trigger for autonomic dysreflexia (AD; hypertension provoked by sensory stimuli below the injury level). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals with SCI. Those with injury at or above T7 were considered at risk for AD. Responses were received from 287 individuals with SCI (injury levels C1-sacral and average duration of injury 17.1 ± 12.9 [standard deviation] years). Survey completion rate was 73% (n = 210). Bowel management was a problem for 78%: it interfered with personal relationships (60%) and prevented staying (62%) and working (41%) away from home. The normal bowel care duration was >60 min in 24% and most used digital rectal stimulation (59%); 33% reported bowel incontinence at least monthly. Of those at risk for AD (n = 163), 74% had AD symptoms during bowel care; 32% described palpitations. AD interfered with activities of daily living in 51%. Longer durations of bowel care (p

In February this year, an inquest into the premature death of a 33-year-old man concluded that gross failures in care had led to his death. Mr Richard Hanley had learning disabilities, some mental health problems and had lifelong constipation. This was managed effectively when he lived in residential care; however, when he moved to supported living he became constipated. His family reported that his abdomen resembled that of a woman about to give birth. Mr Handley was admitted to hospital and 10kg of faeces was surgically removed from his body two days before his death. The coroner determined that the causes of death were inhalation of gastric contents, large bowel obstruction and faecal impaction ( BBC News, 2018 ; Hill, 2018 ; Inquest, 2018 ). Constipation is often considered a minor problem; however, it can have serious and even life-threatening consequences. Each year, 66 287 people are admitted to hospital because of constipation ( Department of Health (DH), 2015 ). The NHS spends around £250 million pounds annually treating constipation. Hospital admissions cost £145 million and primary care spends around £92 million in laxative prescriptions ( DH, 2015 ; Shafe et al, 2011 : NHS Information Centre, 2016 ). This article aims to enable readers to be aware of how normal bowel function varies in individuals, how ageing, frailty, long-term conditions and medication affect bowel function, how to promote normal bowel function and to manage constipation.

**Background:** Neurogenic bowel dysfunction (NBD) is a common sequela in Spinal Cord Injury (SCI) patients. Bowel dysfunction symptoms have a significant negative impact on quality of life (QOL) and are often socially disabling. Transanal irrigation (TAI) is a bowel management procedure that significantly mitigates NBD symptoms in patients refractory to standard bowel care (SBC) by reducing the incidence of fecal incontinence, ameliorating constipation, and improving QOL. TAI devices are used across many countries such as the United Kingdom, Germany, and France, and introduction of the devices is being considered in Japan. In this context, a cost-effectiveness analysis specific to Japanese settings is relevant. **Objectives:** To analyze the cost-effectiveness of TAI for bowel management of SCI patients with NBD in a Japanese clinical setting. **Methods:** A modified version of a previously developed and published Markov model was used to evaluate the cost-effectiveness of TAI. In the model, SCI patients using TAI due to NBD were compared with SCI patients not responding to TAI and continuing with SBC. Quality-adjusted Life Years (QALYs) were used as the primary effectiveness measure, and the analysis was conducted from the payer’s perspective. **Results:** The model predicts a lifetime incremental cost of TAI to be 3 198 687 yen compared with SBC. TAI provided an additional 0.8 QALY, which leads to an incremental cost-effectiveness ratio (ICER) of TAI vs SBC of 4 016 287 yen/QALY. **Conclusions:** An ICER of 4 million yen falls within the range of reported willingness to pay (WTP) per QALY gain (5–6.7 million yen) in Japan, and TAI is therefore found to be a cost-effective treatment strategy compared to SBC. The result should be further corroborated in future Japanese trials of TAI.

Study Objective To assess the effect of common bowel care regimens on return of bowel function following total laparoscopic hysterectomy (TLH). Design A prospective three-arm randomized controlled trial (Canadian Task Force Classification I). Setting Single academic-affiliated institution. Patients or Participants Women aged 18-85 years, without preexisting gastrointestinal disorders, undergoing TLH for benign indications. Interventions Patients were randomized to one of three arms using an equal allocation ratio to receive either no bowel care regimen (control group), docusate sodium, or polyethylene glycol 3350 (PEG) for the first five days following surgery. The primary outcome was time to first bowel movement postoperatively. Secondary outcomes were time to first flatus, total narcotic use in the first five days postoperatively, constipation score, and the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire score. Measurements and Main Results There were no significant differences in time to first bowel movement postoperatively amongst those receiving no bowel care regimen, docusate sodium, or PEG (2.64 ± 1.19, 2.80 ± 1.08, 3.06 ± 1.18 days; p=0.436). Similarly, there were no significant differences in time to first flatus: 1.06 days (interquartile range 0.89-1.70) in the control group, 1.05 days (interquartile range 0.78-1.37) in the docusate sodium group, and 1.11 days (interquartile range 0.82-1.40) in the PEG group (p=0.975). Total narcotic use in the first five days postoperatively, constipation score, and the PAC-SYM score did not vary significantly amongst the groups. Body mass index (BMI) was a significant predictor of time to first bowel movement with an increased BMI associated with a shorter time to first bowel movement [HR 1.05 (1.01, 1.10); p=0.013]. Conclusion In those undergoing laparoscopic hysterectomy for benign indications without any preexisting gastrointestinal disorders, the prescription of a bowel care medication does not significantly affect return of bowel function.

Opioid-induced constipation (OIC) imposes a significant burden for patients taking pain medications, often resulting in decreased quality of life. Treatment of OIC with traditional medications for functional constipation can be incompletely effective, leading to nonadherence with opioid treatment and undertreated pain. An emerging class of medications that counteract the adverse effects of opioids in the gastrointestinal tract while preserving central nervous system-based pain relief may represent a paradigm shift in the prevention and treatment of OIC. One of these medications, naloxegol, is a once-daily, oral opioid antagonist that is effective, well-tolerated, and approved for treatment of OIC in patients with noncancer pain. More studies are needed to demonstrate this same utility in patients with cancer-related pain.

Irritable bowel syndrome (IBS) is the most common cause of non-organic recurrent abdominal pain in children. IBS is a clinical diagnosis, which is based on the Rome IV criteria for functional gastrointestinal disorders in children, as well as the patient's history. The diagnosis of IBS is established following the exclusion of organic causes of recurrent abdominal pain. Staggered investigations should be avoided because they might increase the child's and family's anxiety in the absence of an organic diagnosis. In most cases, providing a positive diagnosis of IBS and explaining the current understanding of the functional pathophysiology of the condition and management strategies gives reassurance to the child and their family. Management is based on dietary, pharmacological and biopsychosocial interventions. IBS can be a debilitating condition, with effects on activities of daily living, education and social interactions. Nurses working in various clinical settings will encounter children with IBS and have an important role in the management of children with this condition.

Patients with fecal incontinence are usually depressed and embarrassed. An abdominal colostomy may then be offered to the patient as a last alternative. A colostomy is well accepted by the patient since it reliably simplifies bowel care and prevents fecal incontinence, and clearly improves quality of life. The option of a colostomy with its pros and cons is explicitly mentioned, but it is also stressed that this should only be considered by them when all alternatives have failed and they are severely inconvenienced by their incontinence. It will be their initiative to start the discussion on a colostomy construction. Mere division of the bowel without resection leaves a rectosigmoideal stump at least 20 to 30 cm long. Since mucus production in the excluded bowel will persist and mucus retention is impossible due to the incontinence-causing impaired sphincter function, a continuous anal drainage of brown-greyish, foul-smelling mucus will occur, wetting and staining the underwear and irritating and eroding the perineal skin.

Persons with spinal cord injury (SCI) have neurogenic bowel disorders characterized by difficulty with evacuation (DWE), fecal incontinence, and discoordination of defecation. Six medically stable in-patients with SCI with a mean age of 57 ± 10 years (range: 39–66 years) and time since injury of 18 ± 17 years (range: 3–47 years) were investigated. Standard of care (SOC) for bowel care was followed by two weeks of SOC plus neostigmine (0.07 mg/kg) and glycopyrrolate (0.014 mg/kg) administered transcutaneously by iontophoresis thrice weekly for two weeks while patients continued to receive SOC. The primary endpoint was time to bowel evacuation. Body weights and abdominal radiographs were obtained. Ten questions related to bowel function and the Treatment Satisfaction Questionnaire for Medication were acquired after each arm. Bowel evacuation time decreased after the dual drug intervention arm (106.9 ± 68.4 vs. 40.8 ± 19.6 min, p &lt, 0.0001). Body weight decreased (2.78 ± 0.98 kg, 0.0001), a finding confirmed on abdominal radiograph. Both questionnaires demonstrated improvement after the dual drug intervention arm. No major adverse events occurred. The addition of neostigmine and glycopyrrolate by transcutaneous administration to SOC for bowel care in persons with SCI and DWE resulted in the safe, effective, and predictable bowel evacuation with subjective improvement in bowel care.

Background: Evidence-based guidelines assist clinicians in practice, but how the guidelines are implemented is less established. Aim: To describe the nurses’ implementation of activities recommended in evidence-based guidelines for falls prevention and care of older people with cognitive impairment. Methods: Structured observation with a categorical checklist was used. Nursing personnel were recruited from one subacute and two acute wards in two hospitals in one tertiary-level health service in south-eastern Queensland, Australia. The data collection instrument identified 31 activities drawn directly from the evidence-based guidelines, which were categorized into six domains of nursing practice: clinical care, comfort, elimination, mobility, nutrition and hydration, and social engagement. Four-hour observation periods, timed to occur across the morning and evening shifts, were conducted over 2 months. Results: Nineteen registered nurses, six enrolled nurses, and 16 assistants in nursing (N = 41) were observed for 155 hr of observation. There was variability in adherence with specific activities, ranging from 21% to 100% adherence. Three categories with the highest adherence were nutrition and hydration, mobilization safety, and social engagement. The clinical care, comfort, and elimination categories had lower adherence, with lowest adherence in activities of education provision about falls risk, pain assessment, using a clock or calendar to reorient to time and place, and bowel care. Linking Evidence to Action: Nursing care is delivered within an interdisciplinary team. Therefore, responsibility for the everyday fundamental care activities known to prevent falls in older people with cognitive impairment requires localized negotiation. A practical guide for preventing in-hospital falls in older people with cognitive impairment addressing the interdisciplinary context of practice is required. Interdisciplinary teams should develop strategies to enhance the implementation of pain assessment and prevention of constipation in the context of regularly implemented hydration, nutrition, and mobilization care strategies.

Of all the health challenges frail elderly face, fecal incontinence is one of the most dreaded. Lack of knowledge within the field of fecal incontinence is evident. With life expectancy lengthening, the percentage of people who will require care in a nursing home will increase in the years to come. Nursing home patients are the most fragile of the older patients. Among this group, there are often problems connected with defecation, such as constipation, diarrhea, and fecal incontinence. Fecal incontinence is a complex problem. It is therefore necessary to have a broad approach to fecal incontinence, and it is important that nurses have high knowledge and advanced skills when it comes to meeting patients’ needs for assessment, care, and treatment. Fecal incontinence can lead to feelings of shame and embarrassment and to a downward spiral of psychological distress, dependency, and poor health. Loose stool, as well as hard stool, can be related to fecal incontinence. Urgency associated with bowel movements is also an important factor. The most important risk factors are functional incapacity, reduced cognitive function, diarrhea, constipation/impaction, stroke, some neurological diseases, diabetes, and comorbidity in general. The level of knowledge among health personnel on the value of good bowel care seems limited. There is at present a relatively limited evidence base from high-quality experimental trials of fecal incontinence, and it remains challenging to provide strong evidence for most interventions. Frail older people require a different care approach addressing the potential role of comorbid disease and current medications, in addition to the functional and cognitive impairment, and should take into account the degree of bother to the person. When appropriate, patient education is important to promote self-management and other coping mechanisms. An environment with physical or social obstacles may impair the ability to maintain continence. This is particularly relevant to individuals who have physical or mental disorders. Good care quality encompasses care personnel to acknowledge the problem of fecal incontinence compassionately. Healthcare personnel should be trained in identification and management of fecal incontinence in nursing home patients.

Continence is one of those clinical conditions that one seldom thinks about if he/she does not have a problem. It to the insurgence and persistence of chronic kidney disease (CKD) and to renal/intestinal failure. Patients with disabilities represent a particularly challenging group, and when growing into adolescents and young adults, they belong to an indeed difficult and unique age group. Currently the published literature on this subject is limited. Many groups have not focused on these nonglamorous aspects of bladder and bowel care. Management of bladder and bowel dysfunction becomes more difficult if associated with disabilities and during the transition between childhood and adulthood. The challenges become enormous if adolescents and young adults are also disabled with unique comorbidities associated and/or leading to bladder and bowel problems. In the presence of obvious physical (motility/sensitivity) and psychological (neurodevelopmental delays, autism, etc.) additional limitations, tailored management needs to be defined. Children with lower IQ associated with physical disability and/or syndromes have an increased risk of incontinence. In this chapter we highlight the need and importance of identifying comorbidities associated with bladder and bowel problems in children and during the delicate transitional phase of adolescence, in individuals affected by disabilities, and to suggest adequate solution to overcome barriers and provide long-term surveillance.

Background Bowel management protocols standardise care and, potentially, improve the incidence of diarrhoea and constipation in intensive care. However, little research exists reporting compliance with such protocols in intensive care throughout patients' stay. Furthermore, there is a limited exploration of the barriers and enablers to bowel management protocols following their implementation, an important aspect of improving compliance. Aim and objective To investigate the impact of a bowel management protocol on the incidence of constipation and diarrhoea, levels of compliance, and to explore the enablers and barriers associated with its use in intensive care. Methods A mixed-methods study was conducted in cardiac intensive care using two phases: (a) a retrospective case review of patients' hospital notes, before and after the protocol implementation, establishing the levels of diarrhoea and constipation and levels of compliance; (b) focus groups involving users of the protocol, 6 months following its implementation, exploring the barriers and enablers in practice. Results and findings Fifty-one patients' notes were reviewed during phase one: 30 pre-implementation and 21 post-implementation. Following the protocol implementation, there was a tendency for a higher incidence of constipation and less severe cases of diarrhoea. Overall compliance with the protocol was low (2.3%). However, there was evidence of behavioural change following protocol implementation, including less variation in aperients given and a shorter, less varied time period between starting enteral feed and administering aperients. Several themes emerged from the focus groups: barriers and enablers to the protocol characteristics and dissemination; barriers to bowel assessment; nurse as a barrier; medical involvement and protocol outcomes. Conclusions The bowel management protocol implementation generated some positive outcomes to bowel care practices. However, compliance was low and until there is improvement, through overcoming the barriers identified, the impact of such protocols in practice will remain largely unknown.

Constipation is a common problem in older people with hip fracture because of immobility, opioid prescription and lack of privacy. There is a dearth of meaningful evidence about the way constipation is recognised and its subsequent treatment. The orthogeriatric team in a university hospital trust investigated the effectiveness of bowel care for older inpatients after hip fracture. Three audits followed a cohort of 40 people aged 60 and older after surgical fixation of hip fracture. After the initial audit in 2010, the expectation was that all hip fracture patients should be started on laxatives on the day of surgery and a chart used to document stool type. Nursing and medical staff needed to ensure that adequate pain control was maintained while opiate analgesia was given only when necessary. Patients with hip fracture are now significantly less constipated. There is improved patient satisfaction with analgesia provision. While laxative prescription is important, a motivated ward team encouraging its uptake is vital. All patients now have a comprehensive record of bowel movements. The improvements demonstrate the importance of a multidisciplinary approach when caring for these patients.

Aim Many patients who are critically ill develop faecal incontinence associated with diarrhoea, and require a bowel management system (BMS) to prevent skin excoriation. Following guidelines produced by the National Institute for Health and Care Excellence, early rehabilitation has resulted in a reduction in the number of days that patients receive mechanical ventilation. However, patients with a BMS are potentially mechanically ventilated for longer because they are cared for in bed. The aim of this evaluation was to investigate whether patients with a BMS are mechanically ventilated for longer than those without a BMS. Method This was a retrospective service evaluation, in which a database search was conducted to identify patients admitted to the critical care department in one healthcare organisation during 2013. The search was narrowed to identify patients admitted to the critical care department who had received advanced respiratory support (mechanical ventilation), to compare the mean number of mechanically ventilated days between patients with and without a BMS (n = 122). Data were analysed using the Mann-Whitney U test. Results There was a significant difference in the number of mechanically ventilated days (P

Background Constipation is a common problem in palliative care, affecting approximately 50% of patients admitted to hospices and causing a wide range of symptoms. It is important to identify, treat and document constipation systematically in order to provide immediate symptomatic relief and to prevent complication occurrence. Aims To identify if there is documented evidence that constipated hospice inpatients are being adequately assessed, monitored and managed, and to implement improvements where necessary. Methods Retrospective audit of constipation assessment and management in twenty consecutive patients admitted to a hospice inpatient unit, against local and national standards. Data collected included documentation of bowel habits, oral laxative prescribing and administration, and rectal interventions. Results A number of areas for improvement were identified in both medical and nursing documentation and clinical practice. Particular areas for improvement included standardisation of documentation, the creation and implementation of appropriate care plans, review and upward titration of oral laxatives, rectal medication administration, and obtaining verbal consent and offering a chaperone prior to bowel examination or intervention. Conclusions Lack of optimal assessment, management and documentation of constipation in hospice inpatients, will impact negatively on their physical and psychological symptom burden. In order to rectify this, a ‘Constipation Working Party’ was established comprising management, nursing and medical staff. Phase 1 of the improvement plan was the implementation of a ‘Bowel Template’ on the electronic patient record, on which all aspects of bowel care can be recorded. This has resulted in constipation documentation being more consistent, accurate and easily accessible. Phase 2 involves the development of hospice constipation guidelines, which are currently underway. Following completion and implementation of the new guidelines, a re-audit of constipation will be conducted to assess the extent to which the interventions have improved documentation and clinical practice.

Context Functional dependence at end of life often leaves individuals requiring help for personal care, including maintaining continence. Current continence guidelines offer little direction for end of life continence care, and little is known of the perspectives of people receiving palliative care. Objectives The aim of the study was to examine the continence care preferences of people receiving palliative care to understand what approaches to care and what goals of care are important to them. Methods This is a qualitative descriptive exploratory study with data gathered in individual interviews using a semi-structured interview guide. Participants were receiving bladder and/or bowel care on either tertiary or hospice palliative care units. Results Fourteen Canadian patients (seven female, seven male), six from tertiary and eight from hospice palliative care units, were recruited. From the analysis, three themes were identified: loss of control, finding a way to manage, and caregivers can help and can hinder. Dignity was often lost as a result of having to receive continence care, with most participants following staff recommendations for management approaches as the easiest way. Patients did not recall being asked about their bladder and bowel preferences. Conclusions As patients approached end of life they were willing to give up dignity if it was required to address symptoms causing them more distress, like pain. Health care professionals and family have an important role in social interactions around continence care. Health care professionals should incorporate patient preferences as best they can and explain the options when treating incontinence at end of life.

A quasi-experimental study tested a clinical benchmarking tool (Essence of Care) to improve bowel-related care for older people living in six care homes. In the intervention care homes, district nurses and care home staff used the clinical benchmarking tool to discuss and plan how to improve bowel care for residents. In the control care homes, staff were provided with detailed information about the residents and continence services contact details. The intervention was acceptable to care home and district nursing staff, and possible to incorporate into existing working patterns. The study did not demonstrate a significant reduction in bowel-related problems, although there was evidence in one care home of reduction in episodes of avoidable faecal incontinence. At an individual level of care, there were observable benefits, and examples of person-centred care were prompted through participating in the intervention and improved staff awareness. Clinical benchmarking tools can be used to structure discussion between district nurses and care home staff to review and plan care for residents. However, it takes time to achieve change and embedding this kind of approach requires either robust pre-existing working relationships or the involvement of a facilitator.

Bowel dysfunction is frequently reported to be a leading cause of reduced quality of life following a spinal cord injury (SCI). There are numerous interventions for neurogenic bowel dysfunction, of which digital removal of faeces is one of the most commonly performed. It is imperative that nurses in the community and acute settings are trained and able to carry out digital removal of faeces when indicated. Failure to provide this care can have serious consequences for the patient, including faecal incontinence, bowel obstruction and autonomic dysreflexia. This literature review assesses the quality of evidence available on digital removal of faeces for people with SCI. It concludes that digital rectal removal of faeces remains a necessary intervention for many patients. More research and training are needed on this and other interventions for neurogenic bowel management. The low status of bowel care in nursing and wider society needs to be challenged so that people with SCI can benefit from high quality bowel care and associated improvements in quality of life.

Background Clostridium difficile infection (CDI) Laboratory identified events are reportable to CMS through the CDC’s NHSN. Diagnostic stewardship has been shown to decrease the incidence by decreasing false-positive incidence. Bowel management systems (BMS) have been associated with transient loss of tone of anal sphincter muscles that result in diarrhea. These episodes of diarrhea may be misdiagnosed as CDI due to a false-positive test result. The objective of this study was to determine whether the use of BMS has resulted in false-positive CDI Lab ID events. Methods We performed a retrospective review of all HO-CDI Lab ID events from October 1, 2016 to December, 31, 2017 in a 1,157-bed tertiary academic medical center. Since 2013, several interventions were implemented to decrease the incidence of CDI Lab ID events. These interventions have included: (i) enhanced environmental cleaning, (ii) CDI testing algorithm, (iii) use of hydrogen peroxide enhanced terminal cleaning of high-risk units, and (iv) computer-assisted decision support diagnostic stewardship. Poisson regression analysis was performed to compare incidence rates. A P-value of ≤0.05 was considered significant. Results A sustained low and decreasing HO-CDI incidence was observed from 2013 to 2017 (7.9, 6.0, 7.1, 6.5 and 5.2 CDI/10,000 patient days; P = 0.01). An incremental decrease was observed when comparing the annual incidence in 2016 to the YTD incidence in 2017 (6.5 vs. 5.2 CDI/10,000 patient days; P < 0.001). Comparing the five quarters before diagnostic stewardship was implemented to post implementation, the CDI incidence decreased from 6.7 to 5.2 CDI events/10,000 patient days (P = 0.009). Of the 180 HO-CDI Lab ID events that occurred post-implementation of the diagnostic stewardship, 31 (17%) were cases in which the computer-assisted alerts were overridden and may have been false positives. An additional 12 (6.7%) cases occurred in patients who had BMS in place within 48 hours and 22 (12%) had BMS in place within 1 week. Conclusion Diagnostic stewardship through computer-assisted decision support is an effective method of reducing false-positive CDI Lab ID events. We found that an additional 12% of the HO-CDI are potentially false positives as these were obtained from patients who had BMS in place immediately before the positive test results. Disclosures All authors: No reported disclosures.

The study was conducted on Effectiveness of self instructional module on knowledge of post operative self care for mothers undergoing elective caesarean section in selected hospitals, Mangalore. The research design was a one group pre test post test design which was a pre experimental research design. 40 mothers undergoing elective caesarean section by purposive sampling.The pretest knowledge questionnaire was administered to the mothers two days prior to caesarean section, followed by a self instructional module on post operative self care. Post test was conducted after 5 days using the same tool. The collected data were analyzed using descriptive and inferential statistics. The mean knowledge score was 14.98 whereas maximum possible score was 30. Among the 11 areas, the mean percentage knowledge score in the area of caesarean section and self care was 77.50% bladder and bowel care was 60% breast feeding was 58.40% diet was 52.50% pain management was 47.50% post operative complications and home care was 46% baby care was 44.33% early ambulation and exercise was 44% perineal hygiene was 41% wound care was 40.67% and deep breathing and coughing was 40.67%.The 't' value showed significant in the post test ('t' calculated value of pretest and post test knowledge scores = 18.000, pThere was significant association between the level of knowledge and demographic variables namely age parity, education, occupation, monthly income, exposure to health awareness and history of caesarean section.

Rationale and key points This article provides practitioners with information about how to perform digital removal of faeces in a safe, effective and patient-centred manner, promoting privacy and dignity. Passing faecal matter is essential to enable the elimination of waste. For some people, however, defecation is not possible without some form of intervention; this could be the administration of oral medication or an enema, insertion of suppositories or digital removal of faeces. ▶ Bowel care is a fundamental aspect of patient care. ▶ Digital removal of faeces should be performed by a practitioner competent in this skill. ▶ Digital removal of faeces is an invasive procedure and should only be carried out when necessary following holistic patient assessment. Reflective activity Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will improve your practice. 2. How the patient receiving the care you delivered might have felt. Subscribers can upload their reflective accounts at: rcni.com/portfolio .

The aim of this longitudinal study with postal survey was to describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades. In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires. Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P