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.
- Multiple sclerosis
- Nerve trauma
- Spinal cord injury
- Pelvic floor relaxation
- Nerve trauma
- Damage to sphincters
- Postoperative injuries
- Fecal impaction
- Hyperosmolar food or fluid intake
- Lack of accessible toileting facilities
Involuntary passage of stool
Patient is continent of stool or reports decreased episodes of
- (i) independent
- (i) Assess patient's normal bowel elimination
- 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
- (i) Determine cause of incontinence (i.e.,
review related factors).
- (i) Perform manual check for fecal
- When patient has a fecal impaction (hard, dry stool that
cannot be expelled normally), liquid stool may leak past the
- (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
- 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
- (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
- (i) Assess patient's ability to go to the
- 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.
- (i) independent
- (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
- (i) Encourage mobility or exercise if
- This enhances gravity, stimulates peristalsis, and aids in
- (i) Provide a bedside commode and
assistive devices (cane, walker) or assistance in reaching the commode or
- (c) Institute a bowel program.
- Facilitating regular time for bowel evacuation prevents the
bowel from emptying sporadically (i.e., decreases incontinence):
- Encourage bowel elimination at the same time every day
- (shortly after breakfast is a good time because the
gastrocolic reflex is stimulated by food or fluid intake).
- After breakfast (or a warm drink), administer a suppository and
perform digital stimulation every 10 to 15 minutes until evacuation
- Place patient in an upright position for defecation.
- Flexion of the thighs (e.g., sitting upright with feet
flat on floor) facilitates muscular movement that aids in defecation.
- (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
- (i) Teach patient/caregiver the causes of
- (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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