Rectal washout

Various methods can be used to empty or clean the bowel. In the majority of cases it is preferable to use laxatives (Rationale 1).

It is important to consider the underlying problem, as laxatives would be contra-indicated in some cases and rectal washouts contra-indicated in others (Rationale 2).

Rectal washouts may be requested to:

• deflate the bowel in Hirschsprungs disease (Molenaar & Meijers 1998)
• prepare the bowel for surgery or investigation
• treat constipation
• control faecal incontinence (Bohr 2009)

Consideration must be given to the psychological affects of rectal procedures in children (Rationale 3). 

Preparation for rectal washout on an older child

Explain the procedure to both the child and the parent/carer(s) (Rationale 4).

Prepare the environment where the washout will be carried out (Rationale 5).

Gather all equipment together (Rationale 6):

• disposable gloves (Rationale 7)
• incontinence sheets
• rectal washout kit (funnel with plastic tubing and connector attached) (Rationale 8)
• rectal tube (sizes of tube that accommodate funnel are 10-18 fr)
• lubricating jelly
• warm saline (Bohr 2009) (Rationale 9)
• bucket
  

Procedure 

• Lower garments should be removed.

• The child should lie on a couch/bed on top of the incontinence sheet.

• Lying on the left side with knees bent up to the abdomen is the preferred position (Rationale 10).

• Tell the child what happens at each stage (Rationale 11).

• Put on disposable gloves.

• Attach the rectal tube to the washout kit.

• Place the bucket on the floor beside the bed/couch

• Pour some saline into the funnel to prime the rectal tube.

• Pinch the rectal tube (Rationale 12).

• Lubricate the end of the rectal tube, locate the anus and gently insert the tube 3-4 inches; this is enough to start the washout (Rationale 13).

• Lift up the funnel to allow the saline to enter the rectum by gravity.  When the saline in the funnel has entered the rectum, lower the funnel and allow saline and stool to run into the bucket (Rationale 14).

• Leaving the rectal tube in the rectum, refill the funnel with saline and repeat the last step. Do not overfill the funnel (Rationale 15).

• The process can continue until the saline runs clear and/or the rectum has emptied (Rationale 16).

• At the end of the washout gently remove the tube.

• It is useful to ask the child to sit on the toilet and try to evacuate any stool or saline that may still be in the bowel (Rationale 17).

Preparation for rectal washout on an infant

• Explain the procedure to the parent/carer(s) (Rationale 18).

• Prepare the environment where the washout will be carried out (Rationale 19).

• Gather equipment together (Rationale 20):

  • Disposable gloves (Rationale 21)

  • Incontinence sheets

  • Warm saline

  • Rectal/naso- gastric tube (10fr or 12fr)

  • 20ml syringe or catheter syringe (Rationale 22)

  • Disposable bowls

  • Lubricating jelly
    

Procedure 

• Undress the infant feet to waist and lay down on incontinence sheets.  Lying prone with feet held up is preferred (Rationale 23).

• Pour warm saline into the bowl, draw up 20mls into the syringe and attach the rectal tube/naso-gastric tube.

• Prime the tube with saline (Rationale 24).

• Put on disposable gloves.  Lubricate the end of the tube.

• Locate the anus and gently insert the tube about 1-2 inches (Rationale 25).

• Slowly inject the saline into the rectum.  Once it has entered gently draw back on the syringe.  If any pressure is felt stop drawing back.  If no saline can be drawn back, disconnect the syringe from the tube and gently move the tube back and forth to stimulate evacuation by gravity (Rationale 26).

• Evacuated stool and saline should be collected in a disposable bowl (Rationale 27).

• No more than 20mls of saline should be instilled at one time.  Medical staff should decide the amounts of saline to be used in pre-term babies (Rationale 28).

• Repeat the above steps until the abdomen is deflated or the saline is running clean (Rationale 29).

• Medical staff may have prescribed how much saline to be used in total.  If not, the warmth of the child should be considered (Rationale 30)

• When the washout is completed gently remove the tube, clean the infant and dress.
  

Rationale

Rationale 1: Laxatives can be a simpler and more effective means of cleaning the bowel, as well as being less embarrassing and uncomfortable for the child.

Rationale 2: If the child has a mechanical obstruction of the bowel, stimulating peristalsis with laxatives can cause increased discomfort and possibly perforation. Children with inflammatory bowel disease have friable bowels and insertion of a rectal catheter or enema nozzle could cause perforation.

Rationale 3: These procedures can be seen as intrusive and in some cases a form of assault (Royal College of Nursing, 2003a; Royal College of Nursing, 2003b).

Rationale 4: This can be a distressing procedure for the child and family, especially as the position a child will assume obstructs his/her view of what the nurse is doing. Allaying fears by explanation can help the child cope with the washout.

Rationale 5: The room needs to be warm as the child will be partly clothed. Privacy is very important due to the nature of the procedure. Toilet, commode or bedpan facilities should be available.

Rationale 6: Having equipment ready ensures that the procedure can be performed efficiently without interruption.

Rationale 7: To adhere to universal precautions.

Rationale 8: Washout kits with rubber tubing should not be used because of the possibility of latex allergy.

Rationale 9: Saline is always used for washouts on children to avoid water intoxication. Warming the saline makes the washout more comfortable.

Rationale 10: This ensures easy insertion of the rectal tube.

Rationale 11: They cannot see what is happening behind them.

Rationale 12: Pinching the rectal tube is the only means of controlling the flow of saline.

Rationale 13: The tube can be introduced further when the rectum is empty. If the tube is not in far enough the saline will run straight back out of the anus.

Rationale 14: Ensure the saline instilled comes back out of the rectum. Moving the tube gently may help evacuate the stool and saline; some may be evacuated around the tube.

Rationale 15: Overfilling the rectum with saline could cause abdominal pain. Reassure the child that the saline will empty back quickly.

Rationale 16: If the washout is a preparation for surgery the bowel needs to be clean. In treatment of constipation the evacuation of stool from the rectum may be all that is needed.

Rationale 17: Sometimes the movement from the couch to the toilet will allow any saline or stool to move down the bowel. This will then evacuate into the toilet.

Rationale 18: This can be a distressing procedure for families of new babies. Explanation throughout the procedure can lessen their distress.

Rationale 19: The room needs to be warm as the infant will be partially clothed.

Rationale 20: To ensure the procedure is uninterrupted.

Rationale 21: To adhere to universal precautions.

Rationale 22: Catheter syringe is needed if a rectal tube is used.

Rationale 23: The infant can potentially assume any position, lying prone with the feet up allows good visibility of the anus, legs cannot kick out and the parents are closer to provide comfort to the infant.

Rationale 24: The tube needs to be primed, as air will be introduced into the rectum. This will cause extra distension of the rectum.

Rationale 25: 1-2 inches is enough to begin with; the rectum can be emptied and the tube can then be advanced more easily if necessary.

Rationale 26: Drawing back on the syringe allows the procedure to be performed more quickly, and will cause no problems as long as there is no pressure felt.

Rationale 27: It is necessary to check the amount of saline being introduced into the bowel is being returned. This is to avoid over-distending the bowel.

Rationale 28: Overfilling the rectum/sigmoid colon could cause distension and possible perforation.
Rationale 29: This will depend upon why the washout has been prescribed. If the washout is bowel prep for surgery the saline should run clean. If the infant has Hirschsprungs disease or is constipated the washout can stop when the abdomen is deflated.
Rationale 30: Attempts should be made to keep the infant warm at all times. If the infant cannot be kept warm the washout should be stopped and if required repeated later.

References

Reference 1:
Molenaar JC, Meijers C (1998) Hirschsprungs disease in paediatric surgery (Chap. 23) Atwell JD In: Paediatric Surgery. London, Edward Arnold Publishers

Reference 2:
Royal College of Nursing (2003a) Digital rectal examination and the manual removal of faeces: the role of the nurse 3rd edition. www.whippsx.nhs.uk/uploaded_files/digital_rectal_examination_adults.pdf. Viewed on: 25/05/2008

Reference 3:
Royal College of Nursing (2003b) Digital rectal examination: Guidance for nurses working with children and young people www.rcn.org.uk/__data/assets/pdf_file/0009/78588/002062.pdf. Viewed on: 25/05/2008

Reference 4:
Bohr C (2009) Using rectal irrigation for faecal incontinence in children Nurs Times 105 (7): 42, 44.

Document control information

Lead author(s)
Helen Johnson, Clinical Nurse Specialist: Stoma Care, Surgery

Document owner
Helen Johnson, Clinical Nurse Specialist: Stoma Care, Surgery

Approved by
Clinical Practice Committee

First introduced: 17 May 2005
Date approved: 2 November 2010
Review schedule: Two years
Next review: 2 November 2012
Document version: 1.1
Replaces version: n/a