a3 - symptom management

Click to edit Master title style

• Click to edit Master text stylesImproving bowel management in a

specialist palliative care service

A clinical project

Emilie Clark - Donny Trust Specialist Nurse Trainee 2014


• Click to edit Master text styles

Background

• Perceived gap in clinical

documentation

• Transition period



Importance of effective bowel management

Constipation is highly prevalent at the end-

of-life.

• Distressing and uncomfortable. Effective management may alleviate distress

(MacLeod, Vella-Brincat & Macleod, 2012).

• 70% of patients receiving palliative care experience constipation during admission to a specialist inpatient unit. (Clark, Smith & Currow, 2012)



Constipation

“It was all I thought about, all the time. I never want to experience that again”

Hospice Patient (2013)



Bowel Care Guidelines

PRINCIPLE Maintenance of palliative

care patient’s own individual bowel

regime and prevention of discomfort

and complications due to

constipation will be achieved by full

assessment, attendance to Bowel Care

Plan and acknowledgement of

the changing condition of the patient.Arohanui Hospice (2013)



Method

1. Was there a nursing bowel assessment completed on admission?

2. Does the patient have an individualised bowel care plan?

3. Are laxatives prescribed regularly for the patient if they are prescribed

opiates?

4. Was the bowel status of the patient recorded on each shift? Including:

–Frequency

–Number of days since bowels last opened

–Bristol Stool Chart

–Quality

–Quantity

–Abnormalities present (if applicable)

5. If interventions were used, was effectiveness documented?



Audit 1 - ResultsAdmission - Was there a bowel assessment on admission?

All

Individualised bowel care plan

7/10 had no plan

2/10 on paraplegic bowel regime

1 had a care plan from PNH – new

colostomy

Laxatives - are the prescribed regularly for those patient with opiates All

If interventions were used, was effectiveness documentedYes - 4/10 had interventions

Recording’s

Minimal recordings of quality using Bristol Stool Chart

Often descriptive wording used eg.

Large, soft.

Erratic documentation - no

structure, sometimes recorded very

well but others no recording at all.

? - used frequently.



Bowel RecordBowel Record

Date Shift Initial Stool Scale

Continent Amount Comments – ie. Description (colour, odour etc), BNO, specimen, melaena, infection control.

(1-7) Y N S M L

Patient Label

Specific Patient Instructions: Diet /fluid specifications: Toileting requirements: Independent/Assistance/Dependent:

Must be filled in EVERY shift, if bowels do not open please record under the COMMENTS.

Royal Melbourne Hospital (2012)



Feedback

• Do you use the bowel chart on a

regular basis?

• Do you find it simple and easy to use?

• Do you feel the form adequately captures the patient’s bowel pattern whilst a patient in the IPU?


• Click to edit Master text styles“The bowel chart is great and a vast improvement on how we were recording bowel routines before.”

“It’s good to have the scale on the chart. At least then we are all reading from the same page.”

“...it’s only as good as the recording and staff need to be responsible.”



Audit 2 - ResultsAdmission - Was there a bowel assessment on admission? All

Individualised bowel care plan

9/10 had no plan

1 had a care plan from the community

palliative care team

Laxatives - are the prescribed regularly for those patient with opiates Yes

If interventions were used, was effectiveness documented None had interventions

Recording’s

Perfect documentation on patient with a care plan

"Unknown" used frequently in regards to

quality of stool.

Not recorded on all shifts majority of the time

- exception is the patient with

care plan and a patient admitted with a

bowel obstruction.



Findings

1. Change

2. Care plans

3. Autonomy and self-recording



Implications for practice

• Further development

• Care plans



Objective or Subjective?

“Different things to different people.” (Andrews & Morgan, 2013)

“Despite the attention of staff on quantifying the frequency or character of the stools, ultimately constipation is a highly subjective sensation”

(Clark & Currow, 2014).



Implications for practice

• Education

• Further research



Any questions?

THANK YOU



References

Arohanui Hospice. (2013). Guidelines service continuum clinical procedures gastro-intestinal bowel care guidelines. Palmerston North: Arohanui Hospice.

Andrews, A., & Morgan, G. (2013). Constipation in palliative care: Treatment options and considerations for individual patient management. International Journal of Palliative Nursing, 19(6), 266-273. Retrieved from ScienceDirect database.

Clark, K., Smith, J.M., & Currow, D.C. (2012). The prevelance of bowel problems reported in a palliative care population. Journal of Pain and Symptom Management, 43(6), 993-1000. Retrieved from ScienceDirect database.

DeRoo, M.L., Leemans, K., Claessan, S.J.J., Cohen, J., Pasman, R.W., Deliens, L., & Francke, A.L. (2013). Quality indicators for palliative care: Update of a systematic review. Journal of Pain and Symptom Management, In Press. Retrieved from ScienceDirect database.

Dhingra, L., Shuk, E., Grossman, B., Strada, A., Wald, E., Portenoy, A., Knotkova, H. & Portenoy, R. (2012). A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliative Medicine, 27(5), 447-456. Retrieved from ProQuest database.

Hospice New Zealand. (2012). Standards for palliative care: Quality review programme and guide 2012. Retrieved from http://www.hospice.org.nz/HNZ_Standards_Book_Online_-_May_2013(1).pdf.

Kyle, G. (2011). End of life: A need for bowel care guidance. Retrieved from http://www.nursingtimes.net/nursing-practice/specialisms/continence/end-of-life-a-need-for-bowel-care-guidance/5029189.article



References

MacLeod, R., Vella-Brincat, J., & Macleod, A.D. (2012). The palliative care handbook: Guidelines for clinical management and symptom control. (6th ed.). Retrieved from http://www.hospice.org.nz/cms_show_download.php?id=377.

Royal Melbourne Hospital. (2012). Bowel Chart.

a3 - symptom management

Health & Medicine

master text stylesdate

master text stylesit

master text styles1

master title stylealladmission

patients bowel

bowel record bowel recordclick

bowel management

bowel chart