Digital removal of faeces (DRF)

Digital removal of faeces (DRF) refers to the use of a gloved lubricated finger, gently inserted into the rectum to remove the stool. This ensures that the lower bowel is empty of faeces, providing some assurance that the person can go about their daily activities with confidence that they will not have an unplanned bowel movement.

It is recommended that this method of bowel management is attended twice a day to prevent the potential for unplanned bowel movements in the evenings, as faeces can ‘move down’ the intestine throughout the day.

The removal of stool from the rectum prevents over-distension and consequent damage to the lower bowel. This method of management is identified as an option for individuals with lower motor neurone (LMN) or cauda equina syndrome (CES) and/or neurogenic bowel dysfunction. Digital removal of faeces helps to empty the lower bowel, preventing unplanned bowel movements secondary to atonic rectal sphincters. It may also be used to complete a bowel routine where upper motor neurone (UMN) ‘reflex’ activity is insufficient to complete bowel elimination.

(Fenton J. (2019) Bowel Care: Management of lower bowel dysfunction including digital rectal examination and digital removal of faeces. Royal College of Nursing) 

Preparation

1. Prepare and set out the required equipment in advance:
   • Non-sterile gloves
   • Apron
   • Water-based lubricant
   • Protective pad (commonly known as a Bluey) if required
   • Soap and water / wipes (for in bed)
   • Plastic bag/bin (for rubbish disposal)
2. Ensure the individual’s dignity and privacy are maintained at all times.
3. Person performing the procedure should introduce themselves, check the person’s identification, explain the procedure, and obtain the person’s verbal consent. (Make it clear that the person can request to stop the procedure immediately, if they wish).
4. 1. If unstable injury:
      • Procedure needs to take place during formal ‘log roll’ procedure.
      • Ensure that correct positioning of the person, such as spinal alignment, is always maintained.
   2. If stable SCI:
      • Procedure can take place in bed
      • Place person in the left lateral position (if possible), flexing the knees to promote stability and expose the anus.
   3. If procedure taking place in shower commode:
      • Position for comfort and anal access.
      • Consider additional needs for safety, such as positioning to ensure anal skin is not stretched during the procedure, using a chest strap in situ and/or using a tilt on the commode chair.
   4. If known to suffer discomfort or signs/symptoms of AD
      • Local anaesthetic gel may be instilled into the rectum 10 minutes prior to procedure.
5. Place protective pad, if required on the bed or floor of bathroom.
6. Wear plastic apron, wash hands and put on a pair of non-sterile gloves.
7. Observe the individual throughout the procedure (especially those at risk of autonomic dysreflexia (AD)).
8. Generously lubricate index finger with water-based lubricant.

Procedure

1. Inform the person that the procedure is about to begin, then slowly and gently insert a single lubricated, gloved finger into rectum (performing a digital check for faeces) and slowly rotate the finger.
2. If stool is a solid mass: push finger into the centre of the stool, split it and remove small sections until none remains.
3. If stool is in small hard lumps: remove each lump, one at a time.
4. Care should be taken to avoid damage to the rectal mucosa and overstretching the external anal sphincters, by gently sliding faeces from the rectum with a straight finger.
5. If stool is soft: gentle circling of the finger may be used to remove the faeces. Continue the process until all faeces is removed from the lower bowel.
6. Dispose of faecal matter in appropriate receptacle.
7. Remove gloves and apron, discard accordingly and perform hand hygiene.
8. Apply non-sterile gloves to clean and dry person’s buttocks and anal area.
9. Reposition person, if required and perform hand hygiene.
10. Record outcome, such as the amount and consistency of the stool (as per the Bristol Stool Scale). See Right consistency for further guidance.
11. Report any abnormalities to the person, team leader or medical officer and document accordingly.