Understanding Bowel Incontinence
Bowel incontinence, medically termed fecal incontinence, signifies the compromised ability to control bowel movements, leading to involuntary stool leakage from the rectum. This condition can stem from nerve or muscle damage affecting normal elimination processes, or it may arise from underlying diseases that disrupt regular defecation function.
It’s crucial to differentiate true anal incontinence, which involves the loss of anal sphincter control causing unintended release of feces or gas, from other conditions resulting in stool passage through the anus. Furthermore, fecal urgency, while related, should be distinguished from fecal incontinence as it can be indicative of medical issues beyond anal sphincter dysfunction (Ferzandi & Strohbehn, 2023).
Several factors contribute to bowel incontinence, including injuries to rectal, anal, or nerve tissues due to trauma, childbirth, radiation exposure, or surgical procedures. Infections leading to diarrhea and neurological disorders like stroke, multiple sclerosis, and diabetes mellitus can also induce bowel incontinence. Furthermore, bowel incontinence is observed in older adults with dementia and can naturally occur with aging.
The true prevalence of fecal incontinence is challenging to ascertain due to underreporting driven by social stigma. Reported prevalence ranges broadly from 2% to 21%. Specifically, about 7% of women under 30 experience fecal incontinence, increasing to 22% in their 70s. Among older adults, prevalence is significantly higher, affecting 25% to 35% of nursing home residents and 10% to 25% of hospitalized clients. Notably, bowel incontinence is the second primary reason for nursing home admissions in the older adult demographic (Roland, 2022).
Nurses must deeply understand the diverse causes of bowel incontinence, as treatment strategies are etiology-dependent. Addressing bowel incontinence is paramount due to its potential to cause discomfort and social isolation. Effective management, focused on re-establishing bowel control and preserving skin integrity, significantly impacts a client’s condition and can contribute to regaining self-esteem.
Nursing Care Plans and Management for Bowel Incontinence
Nursing care plans are integral to managing bowel incontinence. These plans utilize a structured, collaborative approach to enhance client comfort, prevent complications, and restore self-esteem. The ultimate aim is to empower clients to regain control over bowel function and improve their overall quality of life.
Prioritizing Nursing Problems
Key nursing priorities for clients with bowel incontinence include:
Comprehensive Nursing Assessment
A thorough neurological examination is essential, especially when neurological disease is suspected. A detailed rectal examination is pivotal in evaluating bowel incontinence and comprises four key steps: visual inspection, assessment of the anal wink reflex, digital rectal examination, and evaluating anal muscle tone. However, the accuracy of rectal exams and the assessment of related structures heavily relies on the examiner’s clinical expertise (Roland, 2022).
Assess for the following subjective and objective data:
Formulating Nursing Diagnoses
Following a comprehensive assessment, nursing diagnoses are formulated to address the complexities of bowel incontinence. These diagnoses are shaped by the nurse’s clinical judgment and a deep understanding of the patient’s specific condition. While nursing diagnoses provide a framework for care organization, their application can vary across different healthcare settings. Ultimately, the nurse’s proficiency and clinical insight are crucial in tailoring the care plan to best meet individual patient needs. Here are examples of nursing diagnoses relevant to bowel incontinence:
- Bowel Incontinence related to compromised sphincter control and impaired nerve response, as evidenced by frequent, involuntary stool passage and reports of embarrassment and social withdrawal.
- Bowel Incontinence related to decreased muscle tone and impaired voluntary control, as evidenced by involuntary stool leakage and observed use of absorbent pads.
- Bowel Incontinence related to reduced sphincter function and decreased rectal tone, as evidenced by passive stool leakage and documented need for frequent perineal care.
Establishing Nursing Goals
Goals and expected outcomes for managing bowel incontinence may include:
- The client achieves stool continence or reports a significant reduction in bowel incontinence episodes.
- The client actively participates in a structured daily bowel program to establish a regular bowel pattern.
- The client consistently evacuates soft, formed stools.
- The client expresses a sense of self-control regarding bowel movements.
- The client articulates effective strategies for maintaining regular bowel movements, including dietary adjustments and appropriate fluid intake.
Nursing Interventions and Actions
Therapeutic nursing interventions and actions for clients experiencing bowel incontinence are multifaceted and aim to address the condition comprehensively.
1. Restoring Bowel Function
Restoring bowel function requires a multifaceted approach focused on identifying and addressing the underlying causes and empowering the client to regain control over bowel movements. Interventions are tailored to the individual’s specific situation.
Assessing Bowel Continence Participation Ability
Identify the underlying cause of incontinence. Establishing the etiology is fundamental as it guides subsequent interventions. Clients may have multiple contributing factors. Stool seepage leading to underwear soiling can be associated with hemorrhoids, enlarged skin tags, inadequate hygiene, anal fistulas, and rectal mucosal prolapse. Other conditions impacting bowel control include inflammatory bowel disease, laxative abuse, parasitic infections, and exposure to toxins (Ferzandi & Strohbehn, 2023).
Evaluate the client’s typical bowel elimination pattern. Bowel patterns are highly individual. What constitutes “normal” varies widely; some individuals have bowel movements twice daily, while others may have them as infrequently as every three to four days. Many experience the urge to defecate shortly after the first daily oral intake, such as coffee or breakfast, due to the gastrocolic reflex.
Determine medications or treatments potentially contributing to bowel incontinence. Uncontrolled explosive diarrhea can be a consequence of hyperosmolar tube feedings, bowel preparation agents, pelvic or abdominal radiation, certain chemotherapeutic agents, and some antibiotic medications. Antipsychotic-induced incontinence has also been documented, particularly with clozapine and atypicals like olanzapine, asenapine, and risperidone (Singh et al., 2019).
Perform a manual check for fecal impaction. Liquid stool may bypass an impaction, leading to overflow diarrhea when a client has a hard, dry stool they cannot expel. In some cases, spurious or overflow diarrhea may be the presenting symptom. This procedure should be performed using generous lubrication, gently removing impacted stool with a gloved index finger (Setya et al., 2022).
Prepare the client for diagnostic tests. These tests help determine the underlying cause of bowel incontinence. Common tests include flexible sigmoidoscopy, barium enema, colonoscopy, and anal manometry (to assess rectal sphincter function). Diagnostic testing is guided by whether incontinence is associated with stool consistency. If incontinence occurs without diarrhea, more specific investigations are necessary (Roland, 2022).
Evaluate the use of diapers, sanitary napkins, incontinence briefs, fecal collection devices, and underpads. Clients and caregivers may use familiar products like sanitary napkins for fecal containment, especially overnight. Absorbent pads are available in various brands, sizes, absorbencies, and are generally unisex. However, inappropriate absorbency levels can lead to skin damage (Yates, 2017).
Assess the client’s ability to independently use the bathroom. Modifying the environment can prevent accidents related to bathroom access limitations. This assessment also helps determine the client’s level of mobility, coordination, and overall physical capability. This evaluation assists healthcare professionals in identifying any barriers the client faces in accessing restroom facilities.
Assess the female client’s obstetric history. A detailed obstetric history is important. Information regarding the number of vaginal deliveries and any delivery-related risk factors for fecal incontinence should be gathered. Prolonged second stage of labor, forceps delivery, significant perineal tears, and episiotomy are associated with increased risk of anal sphincter disruption and pudendal nerve injury (Ferzandi & Strohbehn, 2023).
Utilize fecal incontinence survey tools for comprehensive assessment. Various surveys aim to quantify and qualify fecal incontinence severity, such as the Fecal Incontinence Quality of Life Scale and the Fecal Incontinence Questionnaire. These tools are valuable outcome measures, efficiently gathering extensive information about client symptoms and their impact in a short timeframe (Ferzandi & Strohbehn, 2023).
Rectal Area Assessment
Assess for the anal wink reflex. This reflex is tested by gently stroking the perianal skin with a cotton swab, which should elicit a brisk contraction of the external anal sphincter. Absence of this reflex can indicate spinal arc disruption and potentially underlying neurological disease (Roland, 2022).
Assist with a digital rectal examination, as indicated. A digital rectal examination is crucial to identify anal pathology and assess resting anal tone. Resistance at the anal verge is expected during examination. Minimal resistance and a patulous anus may suggest significant sphincter dysfunction (Ferzandi & Strohbehn, 2023).
Evaluate resting rectal tone and pelvic floor muscles. During digital rectal examination, assess resting rectal tone to evaluate the internal anal sphincter. Then, instruct the client to bear down to assess puborectalis muscle function (straightening the anorectal angle) and pelvic floor muscle function. Finally, ask the client to squeeze to assess external anal sphincter contraction strength (Roland, 2022).
Medical Management of Bowel Incontinence
Perform manual removal of fecal impaction if necessary. Fecal impaction can disrupt bowel routine establishment. Manual removal is indicated if hard stool is palpable in the rectum. Use ample lubrication and gently remove the impaction with a gloved index finger. An anoscope and suction can sometimes assist (Setya et al., 2022).
Keep a bedside commode and assistive devices readily accessible. Immediate access to appropriate toileting facilities reduces accidents. Clients with fecal incontinence often spend considerable time planning for and worrying about accidents. Time management becomes crucial as symptoms worsen with age, impacting work and daily life (Peden-McAlpine et al., 2018).
Encourage client mobility or exercise, if tolerated. Movement and exercise stimulate peristalsis and aid bowel movements. Pelvic floor activation is linked to abdominal muscle activity and is associated with lifting, spinal stabilization, and functional tasks. This suggests that pelvic floor and body muscles function as an integrated unit, and overall physical activity may benefit pelvic floor function (Staller et al., 2018).
Creating a Bowel Training Program
Establishing a regular bowel elimination schedule helps prevent sporadic bowel emptying. Bowel training aims to develop regular habits and prevent uncontrolled bowel elimination.
Interventions may include:
Encourage bowel elimination at the same time daily. Shortly after breakfast is ideal as the gastrocolic reflex is stimulated by food or fluid intake. Regular, complete bowel emptying promotes continence. Establish a consistent defecation time, and encourage attempts at evacuation within 15 minutes of this time daily.
Administer a suppository and perform digital stimulation every 10 to 15 minutes after breakfast or a warm drink, or before scheduled elimination time. Direct rectal sphincter and lower colon stimulation may be needed to initiate peristalsis in some cases. The anorectal reflex can be stimulated by a rectal suppository or mechanical stimulation. Mechanical stimulation is primarily for clients with disabilities who have no voluntary motor function or sensation due to spinal cord injuries above the sacral segments, such as quadriplegia, high paraplegia, or severe brain injuries. This technique is ineffective if the sacral reflex arc is intact.
Position the client upright or squatting for defecation. An upright or squatting position with feet flat on the floor facilitates muscle movement that aids defecation. The client may assume a squatting position in a private setting if possible. Upright or squatting positions straighten the rectum, facilitating more complete bowel emptying. These positions also promote pelvic floor muscle relaxation, easing stool passage and reducing straining.
Discourage long-term use of pads, diapers, or collection devices for bowel incontinence management. These products are for short-term use to prevent soiling but can cause skin irritation long-term. Prolonged wetness can lead to diaper rash. Chafing can also occur from material rubbing against the skin or skin folds sticking together for extended periods (National Association for Continence, 2022).
Utilizing Fecal Collection Systems
Selectively use fecal collection systems or bowel management systems instead of pads and diapers. These systems collect and dispose of stool without perianal skin exposure, controlling odor and embarrassment. They can also reduce cross-contamination in C. difficile cases and may offer cost savings due to reduced linen use, nursing time, and client complications (Arndt, 2020).
These systems include:
External anal pouch. This device features a bendable wafer with a central opening. One side adheres to perianal skin, and the other connects to a collection bag with a drainable pouch. Properly applied, it can remain in place for 24 hours. Prompt removal is necessary if stool leakage occurs to prevent skin irritation (Mount Sinai, 2022).
Intra-anal stool bag. Made of latex, this bag (20cm non-extended, 26cm extended) is inserted into the anus, secured with a 10cm adhesive attachment around the anus. Application typically requires experienced healthcare professionals to ensure correct positioning and application (Arndt, 2020).
Rectal tubes and catheters. These are inserted into the rectum to direct liquid stool into a collection bag. A balloon near the catheter tip, inflated within the body, prevents leakage around the catheter and tube expulsion during bowel movements. Water or normal saline solution inflates the balloon (Arndt, 2020).
Rectal trumpets. A nasopharyngeal airway connected to a drainage bag forms this device. The wide flange end is inserted into the rectum. Shorter than rectal tubes, trumpets reduce rectal lining damage risk. The narrow end connects to a drainage bag. They have been shown to improve nursing satisfaction and reduce incontinence-associated dermatitis without increasing pressure injury rates. They are also easier and faster to place than adhesive pouches. However, rectal trumpets can cause rectal hemorrhage, potentially leading to PRBC transfusions, hypotension, and invasive procedures (Glass et al., 2018).
Medication Administration
Administer prescribed medications. Medical therapy aims to reduce stool frequency and improve consistency using laxatives, bulking agents, and antimotility medications.
- Bulk-forming laxatives: These agents retain fluid in stool, increasing stool weight and consistency. Psyllium, dietary fiber, and methylcellulose are common examples. Adequate water intake is crucial for their efficacy (Bashir & Sizar, 2022).
- Antimotility agents: For diarrhea of noninfectious origin or reduced rectal compliance due to radiation proctitis or inflammatory bowel disease, agents slowing gut motility can be helpful. Loperamide hydrochloride increases gut transit time, enhancing water absorption from stool, resulting in firmer, more controllable stool. Typical dosing is 2 to 4 mg two to three times daily to manage symptoms (Ferzandi & Strohbehn, 2023).
Assist with biofeedback procedures. Biofeedback is a safe, minimally invasive behavioral technique using auditory or visual feedback to re-educate pelvic floor muscles. Common techniques include rectal sensitivity and anal sphincter strength training (Ferzandi & Strohbehn, 2023).
Surgical Management of Bowel Incontinence
Prepare the client for surgical management and assist as needed. After maximizing medical therapy, minimally invasive and surgical options may be considered. Procedure choice depends on client history, physical exam findings, and diagnostic evaluation results (Ferzandi & Strohbehn, 2023).
Surgical procedures may include:
Anterior sphincteroplasty. This procedure involves dissecting the external anal sphincter, dividing midline scar tissue, and overlapping the muscle to approximate muscle to muscle as closely as possible. Postoperative studies show improved resting and squeeze pressures (Ferzandi & Strohbehn, 2023).
Sacral nerve stimulation. A minimally invasive approach for fecal incontinence, this stimulator benefits clients with minor anal sphincter deficits due to neurological issues. Stimulation reduces fecal incontinence symptoms by enhancing squeeze and resting anal pressures and colonic motility (Roland, 2022).
Internal anal sphincter repair. This surgery requires dissection along the intersphincteric plane and identification of the internal anal sphincter. Studies show improved continence scores in all repair recipients, with some achieving complete continence (Ferzandi & Strohbehn, 2023).
Postanal repair. Some surgeons perform this repair for anal incontinence of neurogenic or idiopathic origin. Clients often have decreased sensation of impending defecation, becoming aware only after stool passage and noticing odor or fecal material around the anus. The initial theory behind postanal repair was restoring the anorectal angle and lengthening the anal canal (Ferzandi & Strohbehn, 2023).
Injection of anal bulking agent. A newer method involves injecting a hyaluronic acid derivative into the anal mucosa. Treatment can be repeated. Early results suggest reduced fecal incontinence episodes in some clients (Roland, 2022).
Artificial bowel sphincter. Designed to mimic a natural anal sphincter in severe fecal incontinence, this implantable device from American Medical Systems is available in the US. An inflatable cuff is placed around the anus, and an inflation reservoir is placed in the space of Retzius. When the urge to defecate arises, a control pump is squeezed, releasing water from the cuff and allowing bowel movement (Ferzandi & Strohbehn, 2023).
Vaginal bowel control device. The Eclipse System, a vaginal insert with an inflatable balloon, offers a conservative, safe, and effective option for fecal incontinence management in women aged 18 to 75 with at least four weekly incontinence episodes. Upon inflation, the balloon applies pressure through the vaginal wall onto the rectal area, reducing incontinence episodes (Ferzandi & Strohbehn, 2023).
Colostomy. When medical and surgical therapies fail, a colostomy may be considered. This converts a perineal stoma to a manageable abdominal stoma, eliminating the constant fear of public humiliation.
Implement necessary postoperative dietary restrictions. Specific dietary restrictions are common postoperatively. Many surgeons delay feeding, starting with clear liquids or soft foods for several days. Others allow a more liberal diet with stool softeners and mineral oil to reduce stool firmness (Ferzandi & Strohbehn, 2023).
Schedule a follow-up four to six weeks post-procedure. Postoperative evaluation should occur four to six weeks after surgery, when swelling and tissue distortion are typically resolved. Assess bowel habits and address issues. Pain control is crucial due to the surgery’s nature and location. Ensure client access to their surgeon for additional pain medication if needed (Ferzandi & Strohbehn, 2023).
2. Maintaining and Improving Skin Integrity
Prolonged fecal matter exposure can cause skin breakdown and pressure injuries. Preventing and managing skin issues through hygiene, protective barriers, and regular skin assessments are nursing priorities.
Performing Skin Assessment
Inspect the client’s skin. Thoroughly inspect skin, including perigenital areas, noting color, turgor, moisture, temperature, and presence of injuries. Adequate lighting is essential to detect subtle color changes. Repeat assessments as needed, especially frequently for incontinent clients at increased risk for IAD (Francis, 2018).
Assess perineal skin integrity. Stool can chemically irritate the skin, exacerbated by diapers, briefs, and underpads. Incontinence-associated dermatitis (IAD), also known as moisture lesions, irritant dermatitis, or perineal rash, is a common skin condition associated with incontinence (Yates, 2017).
Assess for signs and symptoms of incontinence-associated dermatitis (IAD). IAD recognition depends on symptoms like pain, burning, itching, or tingling, blotchy or poorly defined edges of affected areas, kissing ulcers, and intact skin with erythema with or without superficial partial-thickness skin loss. Secondary superficial skin infections like candidiasis may also be present (Yates, 2017).
Utilize valid and reliable skin assessment tools. Assessment is crucial for identifying IAD risk or grading existing IAD severity. Tools used in studies include Incontinence Assessment, IAD Risks Assessment, Skin Damage Assessment, Grade of Skin Damage, IAD Severity Instrument, Ghent Global IAD Categorization Tool, and Skin Moisture Alert Reporting Tool. Healthcare professionals should assess for incontinence causes, IAD risks, and skin damage levels before planning prevention and care (Banharak et al., 2021).
Managing Risk for Skin Injuries
Wash the perineal area with soap and water after each elimination and apply a moisture barrier ointment. Fecal residue can cause irritation, excoriation, and pain, potentially leading to defecation fear, urge denial, impaction, and bowel incontinence. Cleanse skin with a cleanser after each incontinence episode, during/after bathing, and pat dry. Apply a barrier product for skin protection (Canadian Continence Foundation, 2017).
Use soft, gentle materials for perineal cleaning. Clean skin gently with a soft cloth and no-rinse cleanser containing surfactants to loosen irritants. Avoid products requiring rinsing and towel drying, which can cause irritation. Choose a soft cloth to minimize friction and a cleanser with a pH consistent with skin’s acid mantle. All-in-one soft cloths with cleanser, moisturizer, and barrier are also effective and easier to use (Francis, 2018).
Avoid irritating hygienic products. Cleansing products should be alcohol, chemical color, lotion, and perfume/fragrance-free. Skin cleansing pH should be 4.0 to 6.8. Soap and warm water, wet cloths and towels, and alkaline soaps are not recommended. If using soap, liquid soap for children is preferable. Avoid rubbing, wiping, and rinsing (Banharak et al., 2021).
Provide appropriate absorbent products as recommended. Absorbent products and frequent garment changes help keep skin dry and prevent fungal dermatitis. Incontinence pads or briefs wick moisture away from the skin, reducing IAD risk. Limit body-worn briefs to ambulatory clients to avoid fungal dermatitis from perineal occlusion in bed-bound clients (Francis, 2018).
Apply skin protectants or barriers after each cleansing. Apply a direct skin barrier to prevent fecal contact. Baby powder and cornstarch are not barrier products. Use fragrance or lanolin-free barriers. Skin protectant ingredients include:
- Petroleum jelly: Forms an occlusive layer, increasing hydration but may affect pad absorbency. Appears transparent when thinly applied.
- Zinc oxide: Opaque cream, ointment, or paste form. Can be thick, uncomfortable, and needs removal for skin inspection.
- Dimethicone: Silicone-based, non-occlusive, and doesn’t affect pad absorption when used sparingly. Can be opaque or transparent.
- Acrylate terpolymer: Polymer forms a transparent film, allowing skin inspection without removal (Yates, 2017).
Position the client to minimize skin irritation and pressure injury risk. Body positioning can reduce skin irritation. Side-lying positions (right or left) instead of supine can prevent and reduce IAD severity (Banharak et al., 2021). Reposition clients who experience discomfort after 30 to 60 minutes of prone lying. Recumbent position is preferred over semi-Fowler’s to decrease pressure injury risk due to increased body surface support.
Reposition the client frequently, ideally every two hours. Frequent position changes relieve and redistribute pressure, promoting blood flow to skin and subcutaneous tissues. Instruct clients to change position or assist with turning and repositioning.
Educate wheelchair-bound clients on pressure relief techniques. Teach wheelchair users push-ups (lifting buttocks off the seat using armrests), one-half push-ups (alternating sides), lateral shifts, or forward bends to relieve pressure while seated.
Use supportive pillows over bony prominences. Bridging technique with pillows can relieve pressure. Support bony prominences by positioning pillows to create space between them and the mattress. Use pillows or heel protectors to lift heels off the bed for supine clients. Pillows above and below the sacrum relieve sacral pressure.
Encourage a protein-rich diet. Protein-rich nutrition supports faster tissue recovery. Promote protein-rich foods to prevent and aid recovery from IAD and accelerate wound healing (Banharak et al., 2021).
Utilize pressure-relieving devices as recommended. Specialty beds or alternative surfaces can relieve skin pressure. Wheelchair cushions should be fitted and adjusted for clients spending extended periods in wheelchairs, using pressure measurement for guidance. Static support devices distribute pressure evenly. Gel pads and air-fluidized beds reduce pressure. Soft, moisture-absorbing padding aids pressure distribution, moisture dissipation, and wrinkle/friction reduction.
Promote mobility and ROM exercises. Encourage client activity and ambulation whenever possible. Remind seated clients to change positions frequently. Active and passive exercises improve muscle, skin, and vascular tone. Turning and exercise schedules are essential for clients at pressure injury risk.
3. Enhancing Self-Esteem and Reducing Social Isolation
Fecal incontinence significantly impacts quality of life due to shame, embarrassment, decreased self-esteem, and distorted body image (Peden-McAlpine et al., 2018). Clients seeking fecal incontinence evaluation have often overcome considerable embarrassment. Approach this topic with sensitivity to encourage open and comfortable discussion (Ferzandi & Strohbehn, 2023).
Assessing Self-Perception and Body Image
Evaluate the extent to which bowel incontinence modifies daily activities. Fear of uncontrolled bowel elimination can lead to social isolation. Individuals with bowel incontinence are prone to clothing soiling and embarrassment, complicating work and limiting productive activities outside the home. Women may postpone meetings due to symptoms (Peden-McAlpine et al., 2018).
Assess accessibility of toilet facilities in the client’s environment. Limited access to toilets at home, work, or public places intensifies the incontinence experience. Seeking bathroom locations immediately in public and restricting travel to familiar places with careful planning are common considerations to prevent accidents (Peden-McAlpine et al., 2018).
Assess anxiety levels related to social relationships. Clients perceive fecal incontinence as a threat to social acceptance and privacy, impacting relationships. Both men and women experience anxiety due to potential social isolation. Women may have concerns about new relationships due to fear and shame about disclosure (Peden-McAlpine et al., 2018).
Assess the presence and impact of stigma on daily life. Clients with fecal incontinence often self-stigmatize due to symptom control loss. Women particularly report shame and unworthiness. Psychological consultations may be needed due to feelings of inadequacy and vulnerability (Peden-McAlpine et al., 2018).
Identify the client’s self-perception and body image. Fecal incontinence can negatively affect body image and self-esteem, undermining emotional well-being and self-confidence due to embarrassment (Peden-McAlpine et al., 2018).
Interventions to Restore Self-Esteem
Encourage open communication and provide emotional support. Low self-esteem is a common consequence of bowel incontinence. Open communication creates a safe, non-judgmental environment for clients to express feelings and concerns.
Reinforce information about the condition, causes, and management strategies. Education empowers clients and boosts self-esteem. Understanding bowel incontinence as manageable, not a personal failure, instills control and self-confidence in symptom management.
Encourage participation in fulfilling activities and hobbies. Engaging in enjoyable activities enhances self-esteem and relationships, shifting focus from bowel incontinence and fostering accomplishment and fulfillment. Clients regain a positive outlook and purpose by participating in or renewing interests in любимые activities.
Provide positive reinforcement for effort and progress. Acknowledging client efforts and progress in managing their condition builds accomplishment, self-worth, and confidence. Praise and positive feedback reinforce belief in their ability to manage life and condition, positively impacting self-esteem.
Encourage positive coping strategies. Clients should adopt strategies like maintaining hope, optimism, and control. Focus on improvement, reframe incontinence by asserting control, and adapt to obstacles (Peden-McAlpine et al., 2018).
Set meaningful and realistic goals. Goal setting tailors positive coping. Goals include fewer dietary restrictions, reduced leakage during exercise, confidence in symptom control, and normal routines (Peden-McAlpine et al., 2018).
Promote body image-preserving interventions. Clients may preserve body image by carefully choosing clothing to conceal potential accidents. Discreet, disposable pads are preferred over large diaper-like pads due to perceived visibility. Dark clothing helps conceal stains (Peden-McAlpine et al., 2018).
Teach practical symptom management strategies. Preparation is key, including morning bathroom routines, workstation relocation near bathrooms, dietary adjustments, fiber supplements, or anti-diarrheal products. Packing “kits” with absorbent products, cleansing supplies, and extra clothing for unexpected accidents is a common planning strategy (Peden-McAlpine et al., 2018).
Encourage social support from family and friends. Social support, especially from spouses, is crucial. Loving, empathic, unconditional support aids adaptation. Discussing condition-related problems can be comforting (Peden-McAlpine et al., 2018).
4. Preventing Complications
High prevalence of continence issues leads to complications like skin conditions, UTIs, falls, constipation, fecal impactions, dependence loss, and reduced quality of life. Accurate assessment, understanding, and appropriate interventions can prevent these complications (Yates, 2017).
Assessing for Complication Signs
Assess for surgical site infection, bleeding, and hematoma formation. Infection risk post-surgery for fecal incontinence is 3-5%. Monitor for swelling, erythema, worsening pain, and fever, indicating infection. Bleeding and hematoma in the perirectal space can be unnoticed, leading to significant blood sequestration (Ferzandi & Strohbehn, 2023).
Assess pain severity. Pain can be associated with bowel movements and intercourse, causing frustration. Untreated pain can result in mental distress, depression, anxiety, and poor quality of life.
Preventing Infection
Promote meticulous perineal hygiene and guide proper cleansing techniques. Good perineal hygiene is vital in preventing infection. Minimizing skin breakdown, irritation, and infection risk is achieved through regular, meticulous hygiene. Cleansing removes fecal matter, reduces bacterial growth, and maintains skin integrity (Canadian Continence Foundation, 2017).
Administer antimicrobial prophylaxis for colorectal procedures. Preoperative antibiotics should be given. Oral prophylaxis includes neomycin plus erythromycin or neomycin plus metronidazole, starting 18-24 hours pre-surgery. A single preoperative antibiotic dose within one hour before incision is sufficient (Ferzandi & Strohbehn, 2023).
Ensure wound drainage and collection systems function properly. Opening the wound for drainage and antibiotic treatment may salvage surgical repair. Fistula formation is rare (<1%), but more common with infection (Ferzandi & Strohbehn, 2023).
Improving Hydration and Nutritional Status
Assess fluid and fiber intake. Fiber and fluid normalize bowel function, crucial for quality of life in fecal incontinence clients. Regularity, timing, nutrition, fluids, exercise, and positioning promote predictable defecation.
Provide a high-fiber diet under dietitian guidance, unless contraindicated. Insoluble fiber promotes digestive movement and increases stool bulk, benefiting irregular stools. Bulky stool stimulates peristalsis. Diet should include vegetables, fruits, and bran.
Ensure fluid consumption of at least 2000-3000 mL/day, unless contraindicated. Prevents impaction by keeping stool moist. Fluid therapy is vital for diarrhea-related volume replacement. Prune juice (120 mL) 30 minutes before meals can help with impaction.
Encourage natural bulking agents to thicken stools, e.g., bananas, rice, yogurt. These foods absorb stool fluids, adding bulk and consistency, regulating bowel movements by promoting well-formed stools.
5. Client and Caregiver Education
Client and caregiver education is essential for self-management, treatment adherence, and psychosocial well-being in bowel incontinence. It empowers active participation, informed decisions, and strategy implementation for improved bowel control.
Assess client and caregiver readiness for self and home care. Consider individual knowledge, experience, social and cultural background, education level, and psychological status when planning self-care approaches. Preparation should be ongoing, monitored, and updated as clients master self-care aspects. This is also vital for informal caregivers.
Assess the client’s support system. Family caregivers often assume care after discharge. Assess support systems well before discharge. Positive attitudes from family and friends are crucial for successful home transition.
Develop an ADL checklist with client and caregiver. Create methods to help clients and families cope with potential problems. Individualized ADL checklists ensure family proficiency in assisting with tasks.
Provide written instructions and equipment resources for caregivers. Teach equipment use and provide manufacturer’s booklets, resource contacts, supply lists, and procurement locations. Written summaries are essential in family education.
Educate on fluid and fiber importance for soft, bulky stools. Improves personal efficacy and enhances therapeutic regimen compliance. Natural bulking agents and high-fiber foods or supplements add stool bulk, stimulating colon contraction and facilitating predictable bowel movements.
Educate caregivers on fecal device use, if necessary. Provide guidance and feedback for device management. Education reduces client and family discomfort and anxiety. Discuss bowel management program goals and expected benefits.
Educate on proper hygiene and soap/water use, and moisture barriers like zinc oxide or dimethicone. Prevents skin irritation and pain leading to impaction and bowel incontinence. Barriers protect skin from fecal matter. Use barriers, not moisturizers, in the perineal area to prevent irritation and reduce friction from linens, clothing, or pads.
Educate on establishing a regular bowel elimination schedule. Knowledge helps clients and families understand treatment rationale and promotes self-care responsibility. Gastrocolic and duodenocolic reflexes occur ~30 minutes post-meal; breakfast is an ideal bowel evacuation time.
Discuss assistive devices like incontinence pads and provide proper usage instructions. Assistive devices aid home management. Help clients and caregivers choose appropriate products. Absorbent pads vary in brands, sizes, shapes, and absorbencies; informed decisions are crucial for home use.
Refer to support services and community resources. Support service networks enhance independent living. Nurses use collaborative skills to coordinate care, initiate referrals, and advocate for clients when obstacles arise.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
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