Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Bowel Incontinence - Fecal Incontinence
Audrey Klopp, RN, PhD, ET, CS, NHA

NANDA: The state in which an individual experiences a change in normal bowel habits characterized by involuntary passage of stool

Bowel incontinence, also called fecal incontinence, may occur as a result of injury to nerves and other structures involved in normal defecation, or as the result of diseases that alter the normal function of defecation. Treatment of bowel incontinence depends on the cause. Injury to rectal, anal, or nervous tissue, such as from trauma, childbirth, radiation, or surgery, can result in bowel incontinence. Infection with resultant diarrhea, neurological diseases such as stroke, multiple sclerosis, and diabetes mellitus can also result in bowel incontinence. In the elderly, dementia can contribute to bowel incontinence when the individual cannot respond to normal physiological cues. Normal aging causes changes in the intestinal musculature, which may contribute to bowel incontinence. Fecal impaction, as a result of chronic constipation and/or denial of the defecation urge, can result in involuntary leakage of stool past the impaction. Loss of mobility can result in functional bowel incontinence when the person is unable to reach the toilet in a timely manner. Loss of bowel continence is an embarrassing problem that leads to social isolation, and is one of the most common reasons that the elderly are admitted to long-term care facilities. Goals of management include reestablishing a continent bowel elimination pattern, preventing loss of skin integrity, and/or planning management of fecal incontinence in a manner that preserves the individual's self-esteem.

Related Factors

Neuromuscular problems: Musculoskeletal problems:

Defining Characteristics

Involuntary passage of stool

Expected Outcome

Patient is continent of stool or reports decreased episodes of bowel incontinence.

Ongoing Assessment

(i) independent
(c) collaborative
(i) Assess patient's normal bowel elimination pattern.
There is a wide range of "normal" for bowel elimination; some patients have two bowel movements per day, whereas others may have a bowel movement as infrequently as every third or fourth day.
If there is current pathology that may affect bowel elimination, determine premorbid bowel elimination pattern.
Most people feel the urge to defecate shortly after the first oral intake (i.e., coffee, breakfast) of the day; this is a result of the gastrocolic reflex.
(i) Determine cause of incontinence (i.e., review related factors).
(i) Perform manual check for fecal impaction.
When patient has a fecal impaction (hard, dry stool that cannot be expelled normally), liquid stool may leak past the impaction.
(i) Assess whether current medications or treatments may be contributing to bowel incontinence.
Hyperosmolar tube feedings, bowel preparation agents, some chemotherapeutic agents, and certain antibiotic agents may cause explosive diarrhea that the patient cannot control.
(i) Assist in preparing patient for diagnostic measures.
To determine cause(s) of bowel incontinence. Tests include flexible sigmoidoscopy, barium enema, colonoscopy, and anal manometry (study to determine function of rectal sphincters).
(i) Assess degree to which patient's daily activities are altered by bowel incontinence.
Patients may restrict their own activity or become isolated from work, family, and friends because they fear odor and embarrassment.
(i) Assess use of diapers, sanitary napkins, incontinence briefs, fecal collection devices, and underpads.
Patients or caregivers may substitute familiar products (i.e., sanitary napkins) for more appropriate incontinence products out of ignorance or embarrassment.
(i) Assess perineal skin integrity.
Stool can cause chemical irritation to the skin, which may be exacerbated by the use of diapers, incontinence briefs, and underpads.
(i) Assess patient's ability to go to the bathroom independently.
Soiling accidents that occur as the result of the patient's inability to get to the bathroom may be solved by rearranging the environment, planning for trips to the bathroom, or providing a bedside commode.
(i) Assess patient's environment for availability of accessible toilet facility.
(i) Assess fluid and fiber intake.
Both are related to normal bowel evacuation.

Therapeutic Interventions

(i) independent
(c) collaborative
(i) Ensure fluid intake of at least 3000 ml per day, unless contraindicated.
Moist stool moves through the bowel more easily than hard, dry stool and prevents impaction.
(c) Provide high-fiber diet under the direction of a dietitian, unless contraindicated.
Fiber aids in bowel elimination because it is insoluble and absorbs fluid as the stool passes through the bowel; this creates bulk. Bulky stool stimulates peristalsis and expulsion of stool from the bowel.
(i) Manually remove fecal impaction, if present.
(i) Encourage mobility or exercise if tolerated.
This enhances gravity, stimulates peristalsis, and aids in bowel evacuation.
(i) Provide a bedside commode and assistive devices (cane, walker) or assistance in reaching the commode or toilet.
(c) Institute a bowel program.
Facilitating regular time for bowel evacuation prevents the bowel from emptying sporadically (i.e., decreases incontinence):
(i) Treat any perianal irritation with a moisture barrier ointment.
Perineal or perianal pain may result in fear and cause the patient to deny the urge to defecate. Repeated denial of the urge to defecate results in impaction, and eventually bowel incontinence.
(i) Discourage the use of pads, diapers, or collection devices as soon as possible.
(i) Use a fecal incontinence device selectively over pads, diapers, and rectal tubes.
These devices (pouches that adhere to skin around the rectum) allow for collection and disposal of stool without exposing the perianal skin to stool; odor and embarrassment are controlled because the stool is contained. These devices work best for individuals who are in bed the majority of time.

Education/Continuity of Care

(i) independent
(c) collaborative
(i) Teach patient/caregiver the causes of bowel incontinence.
(i) Teach patient/caregiver the importance of fluid and fiber in maintaining soft, bulky stool.
(i) Teach patient the importance of establishing a regular time for bowel evacuation.
(i) Teach caregiver use of fecal incontinence device, if appropriate.
(i) Teach patient to manage perianal irritation prophylactically using moisture barrier ointment.
(i) Teach patient the importance of a regular exercise program.


Bowel Incontinence Care; Bowel Management; Bowel Training; Self-Care Assistance: Toileting

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