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O R I G I N A L A R T I C L E

Effect of quantitative assessment-based nursing intervention
on the bowel function and life quality of patients with
neurogenic bowel dysfunction after spinal cord

injury

Yanyan Zhang MD, RN, Superviser Nurse1 | Xiyan Xia MD, Lecturer2 | Xuewei Zhuang

MD, PhD, Associate Professor3

1Rehabilitation Center, Shandong University

Qilu

Hospital, Jinan, China

2Department of Immunology, Jinan

Vocational College of Nursing, Jinan, China

3Department of Clinical Laboratory

Medicine, Shandong University Qilu

Hospital, Jinan, China

Correspondence

Xuewei Zhuang, Department of Clinical

Laboratory Medicine, Shandong University

Qilu Hospital, Jinan, China.

Email: zhiyuan0517@163.com

Funding information

Shandong Provincial Nature Science Found,

Grant/Award Number: 2015ZRE2757

Aims and objectives: To study the effect of quantitative assessment-based nursing

intervention on the

bowel function and life quality of patients with neurogenic

bowel dysfunction after

spinal cord injury.

Background: Neurogenic bowel dysfunction after spinal cord injury was clinically

manifested by abdominal distension, intractable constipation, prolonged defecation

and faecal incontinence, which seriously affected the normal life of patients. Tradi-

tional ways of nursing for these patients focused on basic care, but lacked sufficient

recognition of disease severity and individual needs.

Design: One hundred and eighty-four patients with neurogenic bowel dysfunction

after spinal cord injury were randomly allocated into observation group (n = 92) and

control group (n = 92).

Methods: The

patients in the control group were given regular nursing, and the

patients in the observation group were given quantitative assessment-based nursing

intervention. Recovery of bowel function, quality of life and satisfaction were com-

pared between the two groups.

Results: Scores for bowel function including bloating, constipation, prolonged defeca-

tion, defecation drug dependence and faecal incontinence in the observation group

were significantly lower than those in the control group (p < .05). The scores for the

quality of life including physical function, general health, social functioning, role-

motional, mental health in the observation group were significantly higher than those in

the control group (p < .001). Finally, the satisfaction rate in the observation group was

95.56%, which was significantly higher than that in the control group (83.7%) (p < .01).

Conclusion: We concluded that quantitative assessment-based nursing intervention con-

tributed to recovery of bowel function and improvement of life quality and satisfaction.

Relevance to clinical practice: Our finding can increase the rational allocation of

nurse–patient ratio and provide personalised nursing for severe patients to reduce

complications and promote the rehabilitation of the disease. Our findings can also

serve as a reference for other coun

tries to develop the

nurse practitioner role.

K E Y W O R D S

neurogenic bowel dysfunction, nursing interventions, quantitative assessment, spinal cord

injury

Accepted: 19 November 2017

DOI: 10.1111/jocn.14198

e1146 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:e1146–e1151.

http://orcid.org/0000-0002-6819-2024

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http://orcid.org/0000-0002-6819-2024

http://wileyonlinelibrary.com/journal/JOCN

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1 | INTRODUCTION

Patients with spinal cord injury (SCI) is associated with autonomic

dysreflexia (Furusawa et al., 2011), serious upper and lower neuro-

genic bowel dysfunction (NBD)(Preziosi & Emmanuel, 2009; Gondim,

de Oliveira, & Thomas, 2010). NBD after SCI was clinically mani-

fested by abdominal distension, intractable constipation, prolonged

defecation and faecal incontinence, which seriously affected the nor-

mal life of patients (Zhu & Liu, 2012). Traditional ways of nursing for

these patients focused on basic care, but lacked sufficient recogni-

tion of disease severity and individual needs. Through comprehen-

sive evaluation of the patient’s symptoms, laboratory and

radiological results, quantitative assessment-based nursing interven-

tion can identify the most urgent care needs and provide person-

alised nursing

intervention to reduce complications and promote the

rehabilitation of the disease (Huang & He, 2012). In this study, we

determined the effect of quantitative assessment-based nursing

intervention on the bowel function and quality of life in patients

with neurogenic bowel dysfunction after spinal cord injury.

1.1 | Background

Spinal cord injury was associated with not only in motor and sensory

deficits but also in autonomic dysfunctions. This included compro-

mised cardiovascular, respiratory, urinary, gastrointestinal, ther-

moregulatory and sexual activities. In particularly, neurogenic bowel

dysfunction with constipation and/or incontinence was a critical con-

sequence of SCI (Hou & Rabchevsky, 2014). Faecal incontinence in

SCI is due to loss of recto-anal sensitivity and loss of voluntary con-

trol of the external anal sphincter. Constipation is due to immobilisa-

tion, abnormal recto-anal reflexes and colonic contractility (Krogh &

Christensen, 2009). Traditional methods of nursing were stereotyped

and emphasise only on the treatment of diseases and basic care,

which ignored the impact of the disease on the quality of care and

quality of treatment. Therefore, traditional nursing cannot meet the

patients’ physical and psychological needs. Management of NBD

after SCI is complicated and remains conservative (Coggrave, Norton,

& Wilson-Barnett, 2009). Many therapeutic protocols for NBD, such

as treatment with oral laxatives and abdominal massage, have been

reported (Ayas�, Leblebici, S€ozay, Bayramo�glu, & Niron, 2006; Cog-
grave & Norton, 2010). Studies have shown that quantitative assess-

ment-based nursing intervention can fully evaluate and consider the

patients’ own disease condition, and execute individualised nursing

intervention programmes, which can maximally meet the patients’

care needs, improve the care’s quality and promote the rehabilitation

of patients.

2 | METHODS

2.1 | Aim

The aim of the study was to determine the effect of quantitative

assessment-based nursing intervention on the bowel function and

life quality in patients with neuro/genic bowel dysfunction after

spinal cord injury.

2.2 | Design

Patients were randomly allocated into observation group (n = 92)

and control group (n = 92) by means of random number table. The

patients in the control group were given regular nursing, and the

patients in the observation group were given quantitative assess-

ment-based nursing intervention. Recovery of bowel function, quality

of life and satisfaction were compared between the two groups.

2.3 | Participants

Patients included 113 males and 71 females between the ages of

35–70 years. There were 73 cases of complete injury, 58 cases of

lumbosacral injury, 40 cases of cervical spinal cord injury and 13

cases of thoracic spinal cord injury. The gender, age and the type of

spinal cord injury were not significantly different between the obser-

vation group and control group.

2.4 | Data collection

2.4.1 | Nursing in the control group

The patients in the control group were provided with routine nurs-

ing, including disease health education, psychological care, guiding

patients to eat more fresh vegetables, fruits and high dietary fibre

foods, and drink sufficient water, promoting bowel patency, eating

less candy and milk that produce gas and reducing bloating. For

patients with severe constipation, senna, fruit and other drugs

catharsis were used. If necessary, artificial catharsis was performed

(Hu, 2013).

2.4.2 | Nursing in the observation group

The detailed nursing in the observation group was described below.

What does this study contribute to the wider

global clinical community?

• Through comprehensive evaluation of the patient’s symp-

toms, laboratory and radiological results, quantitative

assessment-based nursing intervention can identify the

most urgent care needs and provide personalised nursing

intervention to reduce complications and promote the

rehabilitation of the disease.

• Our finding can be used as a assessment tool for continu-

ing education of nurse practitioners.

• Our findings can also serve as a reference for other coun-

tries to develop the nurse practitioner role.

ZHANG ET AL. | e1147

Quantitative assessment: According to basic signs, clinical symp-

toms, laboratory tests and radiographic results, patients were given a

score of 0.5, 1.0 and 1.5 for mild, moderate and severe, respectively.

If patients over 55 years old, the total score was added with 0.5 for

every 5 years of the age. The total score for each patient was subse-

quently obtained.

Nurse–patient ratio: According to the quantitative evaluation, the

ratio of nurses to patients was adjusted. For patients with mild dis-

ease, the nurse–patient ratio was 1:3. For patients with moderate

disease, the nurse–patient ratio was 1:2. For patients with severe

disease, the nurse–patient ratio was 1:1. All nurses who have been

provided with organised trainings and grasped quantitative evalua-

tion method can carry out personalised nursing inter

vention.

Personalised nursing intervention: (i) Intake of high-fat and

high-protein foods was reduced. When the condition permits, daily

fluid intake was minimum of 2000 ml. (ii) Abdominal massage was

performed to speed up bowel movements. During the massage, the

patients were in supine position. The navel was used as the centre,

and a nurse used one or both hands’ fingers, massage from right

to left along the colon anatomical location of circular and lasted

for 10–15 min. Massage was performed 1 time/day, 1–2 times/day

and 2 times/day for patients with mild, moderate and severe condi-

tions, respectively. During the massage, the patient was relaxed

with calm breathing. The massage intensity should be moderate

without causing pain to the patients. (iii) Exercise the muscles

involved in defecation: the patients were guided to exercise

abdominal muscles. Patients sit on toilet or adopted a bed slope

position. The abdominal muscle was exercised through deep

breathing, abdominal breathing and actions of defecation. The

patients were taught to correctly execute anal contraction exercise.

The patients were in supine position with both legs together and

knees buckling slightly separated. The patients were instructed to

lift the buttocks and contracted the anus. During the anal contrac-

tion, perineal muscle and thigh muscle were contracted for 5s and

then relaxed for 3s. A consecutive of 10-20 contraction and relax

was considered one group and a total of 4–6 groups were exer-

cised each day. (iv) Stimulate the anus and promote the colorectal

reflection: Anal action can stimulate the peristaltic activity of intes-

tine.(Li & He, 2002). Nurses or family members wore gloves with

liquid paraffin lubrication on forefinger and middle finger, slowly

inserted into the anus and rotated in the rectum. Such mechanical

stimulation was performed at the position of 3, 6, 9 at 12 o’clock.

For patients with severe constipation and prolonged defecation,

faeces were removed before anal action. Anal action was per-

formed daily and lasted for 1 min.

2.5 |

Parameters

2.5.1 | Bowel dysfunction

After nursing intervention in both groups, bloating, constipation, pro-

longed excretion, drug-dependent defecation and bowel inconti-

nence were scored. The score for incontinence including the type

and frequency of incontinence ranged from 0–20 points. Higher

score indicated more severe incontinence.

2.5.2 | Quality of life

At the day of admittance and 1 day before discharge, the quality of

life for all patients was evaluated by SF-36 questionnaire (Sang,

Pang, Zhang, & Wang, 2014). This questionnaire has been verified to

have good reliability with a half coefficient c = 0.726~0.975, and

coefficient of internal consistency Cronbach’a=0.755~0.826. A total

of 10 items for physical function (PF), four items for role-physical

(RE), two items for bodily pain (BP), five items for general health

(GH), four items for vitality (VT), two items for social functioning

(SF), three items for role-motional (RM) and five items for mental

health (MH) were included in the questionnaire. The score for each

item ranged from 0–100. Higher score indicated better quality of

life.

2.5.3 | Satisfaction

We used our home-made questionnaire to determine the satisfaction

of the patients. The questionnaire had three levels: satisfaction, gen-

eral satisfaction and nonsatisfaction. The satisfaction rate indicates

the percentage of patients with general satisfaction or satisfaction.

2.6 | Ethical consideration

Ethical approval was granted by Ethics Committee of Qilu Hospital,

and patients voluntarily signed an informed consent.

2.7 | Data analysis

SPSS 20.0 software was used for statistical analysis of data. Student

t test was used to compare the quality-of-life scores between the

two groups. The chi-square test was used to compare the bowel

function and satisfaction. p < .05 was considered statistically signifi-

cant.

3 | RESULTS

3.1 | Comparison of bowel function between
observation and control groups

The scores for abdominal distension, prolonged defecation, drug-

dependent defecation and faecal incontinence in the observation

group were significantly lower than those in the constipation control

group (p < .05) (Table 1).

3.2 | Comparison of life quality between
observation and control groups

The scores of life quality parameters (PF, RE, BP, GH, VT, MG, RE

and MH) at the day of admittance were not significantly different

e1148 | ZHANG ET AL.

between the observation group and control group (p > .05). Com-

pared with the day of admittance, the scores of life quality parame-

ters (PF, RE, BP, GH, VT, MG, RE and MH) 1 day before discharge

were significantly increased in both observation group and control

group (p < .01) (Table 2). The scores for RE, GH, SF, RM and MH in

the observation group were significantly higher than those in the

control group (p < .001) (Table 3).

3.3 | Comparison of satisfaction rate between
observation and control groups

The satisfaction rate in the observation group was 95.56% (69 cases

of satisfaction and 19 cases of general satisfaction), which was sig-

nificantly higher than that in the control group (p < .01) (Table 4).

4 | DISCUSSION

The integrity of the nervous system in patients with spinal cord

injury is destroyed, which may lead to symptoms related to sensory

dysfunction, motor dysfunction and reflex dysfunction (Whiteneck

et al., 2011). Therefore, spinal cord injury has many complications,

mainly manifested by the local soft tissue damage, pulmonary infec-

tion and urinary retention. Bowel dysfunction after spinal cord injury

may result in constipation, bloating, prolonged defecation and faecal

incontinence. Severe cases can even have mechanical obstruction

due to faecal accumulates (Cong et al., 2012). The lack of gastrocolic

reflection after spinal cord injury slows down colon peristalsis. The

injury of nerves that control rectal defecation reflex results in the

disappearance of defecation reflex. Prolonged stay of stool in rectum

and water absorption led to the occurrence of dry stool (Ozisler,

Koklu, Ozel, & Unsal-Delialioglu, 2015). Due to the bowel dysfunc-

tion, patient diet is limited and they cannot participate in normal

work and life. Furthermore, long-term bowel dysfunction can also

TABLE 1 Comparison of bowel function between the two groups

Abdominal distensiona N (%) Constipationa N (%) Drug-dependenta N (%) Defecation timeb �X�s Faecal incontinenceb �X�s
Observation 18 (19.57) 15 (16.30) 12 (13.04) 14.06 � 3.87 9.68 � 0.61
Control 35 (38.04) 31 (33.70) 27 (29.35) 18.65 � 4.23 10.57 � 0.84
p <.05 <.05 <.05 <.05 <.05

aChi-square test.
bt test.

TABLE 2 Comparison of quality of life within groups (�X�s)

Parameters

Observation group Control group

At the day of admittance 1 day before discharge p At the day of admittance 1 day before discharge p

Physical functioning 66.18 � 6.69 74.03 � 7.15 <.01 65.79 � 6.27 73.14 � 7.41 <.01 Role-physical 44.95 � 5.34 62.56 � 6.37 <.01 45.08 � 5.16 56.32 � 5.76 <.01 Bodily pain 60.68 � 6.37 68.61 � 7.24 <.01 60.49 � 6.24 68.05 � 7.09 <.01 General health 49.43 � 5.46 67.22 � 6.63 <.01 48.97 � 5.61 63.17 � 6.15 <.01 Vitality 60.45 � 6.71 75.34 � 7.86 <.01 60.72 � 6.39 73.41 � 6.93 <.01 Social functioning 51.35 � 5.47 60.61 � 6.38 <.01 50.82 � 5.06 54.82 � 5.71 <.01 Role-motional 43.16 � 4.53 55.35 � 5.02 <.01 43.27 � 4.31 50.42 � 4.78 <.01 Mental health 40.39 � 4.28 57.09 � 6.16 <.01 40.12 � 4.78 51.17 � 5.69 <.01

Student’s t test for paired samples.

TABLE 3 Comparison of quality of life between the two groups 1
day before discharge (�X�s)

Observation group Control group

p

1 day before
discharge

1 day before
discharge

Physical functioning 74.03 � 7.15 73.14 � 7.41 >.05
Role-physical 62.56 � 6.37 56.32 � 5.76 <.001 Bodily pain 68.61 � 7.24 68.05 � 7.09 >.05
General health 67.22 � 6.63 63.17 � 6.15 <.001 Vitality 75.34 � 7.86 73.41 � 6.93 >.05
Social functioning 60.61 � 6.38 54.82 � 5.71 <.001 Role-motional 55.35 � 5.02 50.42 � 4.78 <.001 Mental health 57.09 � 6.16 51.17 � 5.69 <.001

t test for independent samples.

TABLE 4 Comparison of satisfaction between the two groups

Groups Case No.
Nonsatisfaction
N (%)

Satisfaction rate
N (%)

Observation group 92 4 (4.35) 88 (95.56)

Control group 92 15 (16.30) 77 (83.70)

Chi-square test, p < .01.

ZHANG ET AL. | e1149

increase mental stress, leading to anxiety, depression and other neg-

ative emotions, which seriously affects the quality of life (Long, Gao,

& Xu, 2015). Therefore, it is very important to implement high-qual-

ity nursing intervention to reduce related symptoms.

In this study, we developed quantitative assessment-based nurs-

ing interventions for patients with bowel dysfunction after spinal

cord injury, which makes nursing more targeted and efficient. With

the rational allocation of nurse–patient ratio and intensive care for

severe patients, we showed that scores for bloating, constipation,

prolonged defecation, defecation drug dependence and faecal incon-

tinence in the observation group were significantly decreased com-

pared to those in the control group, which is consistent with

previous reports (Hsieh et al., 2013). These results suggested that

quantitative assessment-based nursing intervention can improve the

patients’ bowel function.

Effective bowel movements and the involvement of abdominal

and pelvic muscles are important for normal defecation (Xiao et al.,

2014). Based on the severity of spinal cord injury and bowel dys-

function, we executed individualised nursing intervention. Through

abdominal massage, sit-ups, abdominal breathing and anal contrac-

tion, the muscles involved in defecation were exercised. Artificial

mechanical stimulation of the anus and other forms of nursing inter-

vention were carried out to stimulate defecation reflex, promote

smooth bowel movements and foster bowel habits of defecation and

thus reduce bloating, constipation, prolonged bowel dysfunction and

the occurrence of drug-dependent defecation stool incontinence.

After the bowel function was improved, patients can be involved in

normal work and social participation, and thus, quality of life was

improved (Liu, 2012). Based on SF-36 questionnaire, the scores for

RE, GH, SF, RM and MH were significantly higher in the observation

group than in the control group, suggesting that quantitative assess-

ment-based nursing intervention included abdominal massage and

anal stimulation can improve patients’ life quality. Similar results

have also been reported previously (Awad et al., 2013; Li, 2012). We

recommend that individualised nursing intervention should be

included in rehabilitation programmes for patients with SCI because

this therapy can relieve some clinical components of neurogenic

bowel dysfunction.

Limitations of this study include the small sample size and the

deficiency of study design. It must be noted that we need to expand

our sample size to efficiently integrate the quantitative assessment

into the nursing intervention strategies because quantitative evalua-

tion involves patients’ both physiological and psychological aspects.

Nursing intervention is one of the rehabilitation programmes for

patients with SCI, which is not appropriate for determining the

effectiveness of treatment.

4.1 | Rigour

Inclusion criteria of patients were randomly allocated into observa-

tion group (n = 92) and control group (n = 92): (i) consistent with

diagnostic criteria for spinal cord injury and neurogenic bowel dys-

function; (ii) confirmation by X-ray, CT and/or MRI examination;

however, patients with previous history of intestinal disorders or

unwilling to cooperate in the assessment were excluded. All nurses

who have been provided with organised trainings and grasped quan-

titative evaluation method can carry out personalised nursing inter-

vention.

5 | CONCLUSION

In summary, quantitative assessment-based nursing intervention can

promote the recovery of bowel function, improve the life quality of

patients with neurogenic bowel dysfunction after spinal cord injury

and improve patients’ satisfaction.

6 | RELEVANCE TO CLINICAL PRACTICE

Our finding can increase the rational allocation of nurse–patient ratio

and provide personalised nursing for severe patients to reduce com-

plications and promote the rehabilitation of the disease. Our findings

can also serve as a reference for other countries to develop the

nurse practitioner role.

ACKNOWLEDGEMENTS

This study was supported in part by grants from Shandong Provincial

Nature Science Found (2015ZRE2757).

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

CONTRIBUTIONS

Study design: YZ, XZ; data collection and analysis: YZ, XX; and

manuscript preparation: XZ.

ORCID

Xuewei Zhuang http://orcid.org/0000-0002-6819-2024

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How to cite this article: Zhang Y, Xia X, Zhuang X. Effect of

quantitative assessment-based nursing intervention on the

bowel function and life quality of patients with neurogenic

bowel dysfunction after spinal cord injury. J Clin Nurs.

2018;27:e1146–e1151. https://doi.org/10.1111/jocn.14198

ZHANG ET AL. | e1151

https://doi.org/10.1038/sc.2009.166

https://doi.org/10.1038/sc.2008.137

https://doi.org/10.1038/sc.2010.94

https://doi.org/10.1002/cphy.c130045

https://doi.org/10.1002/cphy.c130045

https://doi.org/10.1016/j.apmr.2012.10.038

https://doi.org/10.1016/j.apmr.2012.10.038

https://doi.org/10.1016/j.bpg.2009.04.012

https://doi.org/10.4103/1673-5374.160112

https://doi.org/10.1586/egh.09.31

https://doi.org/10.1586/egh.09.31

https://doi.org/10.1016/j.apmr.2010.07.241

https://doi.org/10.1016/j.apmr.2010.07.241

https://doi.org/10.1111/jocn.14198

Purpose:  Summarize and appraise an article for bias and validity in a collaborative environment.

Instructions: Carefully read, summarize, and appraise your group’s assigned article. 

1. Identify and discuss the following:

· what is known/not known about the topic and the gap in knowledge the study is intended to fill.

· the research design, purpose of the study, and setting.

· information about the sample: 

· method;

· size;

· inclusion/exclusion criteria,

· attrition/loss to follow up/response rate, if any;

· important characteristics of the sample.

2. Appraise and debate the sampling methods. Consider the following questions:

· Was the sampling method and inclusion/exclusion criteria adequate to reduce sampling bias?

· Do the sample characteristics representative of the target population?

· Was the sample size adequate?

· Was there a decrease in sample size?  If so, did the researchers identify decreases early and attempt to reduce the impact?  Was a decrease, if any, adequately explained by the researchers?

· How would you rate the quality of the sampling procedures and your confidence in drawing inferences to the target population?