To develop appropriate care plans for bowel incontinence, it might help to first define the characteristics of this condition. These include being unable to put off defecation, urgent rectal sensation, faces-type odor, incessant flow of soft stool, fecal stains on underclothing, redness of skin around the anal region, unable to recognize or incapable of paying attention to the need to defecate, patient reports they cannot feel fullness in the rectal area or the existence of stool in their bowel, patient recognizes feelings of fullness in the rectal region but says they are unable to expel fully-formed stools.
Factors Related to Bowel Incontinence:
- Abnormal independent movement or motility (intolerance towards food, disease of infectious varieties, metabolic-type disorders, inflammation of the bowel and related diseases, motility-type disorders induced by drugs);
- Alteration in consistency of stool (constipation, diarrhea, impaction of fecal matter);
- Neurological conditions and disorders that impact food movement from entering the mouth to expulsion from the body and the functioning of the sphincter and rectal cavity or vault (injury to spine, stroke, encephalopathy, traumatic injury to the brain, advanced dementia, tumor development in the central nervous system, encephalopathy, myelodysplasia and defects related to the neural tube, multiple sclerosis, severe alcoholism, gastroparesis (digestive disorder) in diabetes patients, autoimmune or infectious neurological and neuromuscular illnesses including myasthenia gravis, serious mental disorders or retardation, and metal toxicity or poisoning (resulting from certain heavy metals);
- Defects or abnormalities in the functioning of the rectal ampulla (poor rectal activity as a result of chest pain or ischemia, radiation, fibrosis, proctitis (the infectious variety), Hirschprung's (affects the colon or large intestine) disease, severe or extreme rectocele, infiltrating or local neoplasm);
- Sphincterdisorder or dysfunction (prolapse, abscess or fistula, hemorrhoids of the third degree variety, incontinence caused by trauma or obstetrics, or muscles in the pelvic area are affected by a urological condition or pseudodyssynergia);
Nursing Outcomes Classification (NOC)
Suggested Labels for NOCs
• Bowel and/or Fecal Continence
• Elimination (or emptying) of bowel content
- Complete and regular emptying of fecal matter from patient's rectal ampulla/vault.
- Expels soft stools (formed stools).
- Perianal skin remains intact.
- Non-existence or fewer incidents of bowel incontinence.
- Increased strength of pelvic muscle - patient shows they are able to contract, relax, and isolate these muscles.
Nursing Intervention Classifications (NIC)
Suggested Labels for NICs
- Training of the bowel.
- Development of effective care plans for bowel incontinence.
- Provision of care for encopresis(bowel leakage or incontinence).
Rationales and InterventionsBy Nursing Professionals
- In order to devise individualized care plans for bowel incontinence, nurses can directly ask a patient who is suffering from - or at risk of the possibility of - bowel control disorders a series of direct questions. Obviously, such consultations should be held in private. In the event the patient describes any changes to their normal bowel emptying patterns, any problems with “unsuppressible” diarrhea, or problems controlling bowel activity, the nurse should carefully check the patient's medical history. This might include checking the patient's dietary habits and history, their present and past bowel expulsion patterns or routines, the volume and frequency of unsuppressible stool expulsion, and any other alleviating or exacerbating factors. Patients are likely to be reluctant to volunteer information about fecal leakage unless they are asked direct questions. Their history will then determine the patient's bowel elimination patterns to create a picture of the involuntary expulsion of stool and the most likely origins and/or causes of the patient's incontinence.
- Nursing staff should undertake a focused and thorough physical examination of the patient. This generally includes inspecting the skin around the perianal region, assessing the strength of the pelvic muscles, examining the patient's rectum (using digital methods) for signs of fecal impactation and the condition (strength) of the anal sphincter (AS), and evaluating AS functional capability (based on visual appearance, dexterity, and mobility). This physical examination should enable the nurse to determine how severe the bowel leakage is and what is likely to be causing it. An evaluation of the functional aspects provides the nurse with information about the presence of incontinency and stool expulsion patterns.
- Nurses should assess the patient's cognitive or mental state with respect to their ability to function normally. Bowel incontinence can be the result of severe confusion, dementia, and mental disorder or retardation.
- Nurses should keep a record of the patient's bowel trends wherein they document stool expulsion patterns, to include details of the patient's fluid consumption, dietary habits, bowel movement frequency, consistency of stool, severity and frequency of incidents of incontinence, and other possible contributing factors. Nursing staff can then use this record to verify any verbal accounts of the patient's history and to help determine the possible cause(s) of any bowel incontinence. This documentation can also be used in a baseline capacity to measure or evaluate the effectiveness of any treatment(s).
- Nurses should then attempt to establish the possible causes or origins of the bowel incontinence symptoms. Very often, a number of factors contribute to this condition. Hence, it is necessary to identify the likely causes in order to choose an appropriate course of treatment to eliminate or control it.
In this sample nursing care plan for bowel incontinence, the next intervention concerns improving toileting access:
- Establish the usual or current toileting routines of patients receiving long-term or acute/intensive care and draw up toileting opportunities in accordance with these patterns.
- An effective nursing care plan for bowel and bladder incontinence should include a toileting routine or program that prompts patients whose cognitive abilities is impaired.
- Arrange toileting assistance for patients who have reduced access or whose functional ability is impaired.
- Provide prompt toileting assistance to patients who request such help.
- Ensure there is sufficient privacy for patient toileting.
In cases where incidents of incontinence are intermittent, nursing staff should establish patient re-education or training programs to consist of:
- Regulating the consistency of stool with adequate amounts of fluids, a proper diet, and supplementary fiber intake.
- When indicated, cleanse impacted fecal matter from the bowel.
- Create a routine of regular bowel elimination according to established methods for achieving this.
- Implement prompted toileting or defecation programs - to include fecal and urine elimination - for adult patients with learning difficulties, dementia, mental disorder such as retardation and other related disabilities. It has been shown that theseprompted programs are effective at eliminating or reducing incidents of incontinence in long-term or permanent care facilities and in communities.
Establish stimulated and scheduled versions of these programs (defecation or toileting programs) for patients whose incontinence conditions are caused by neurological ailments, to include the steps below:
- Cleanse impacted stool or fecal matter from the bowel before starting the program.
- Develop strategies that will normalize the consistency of fecal matter. These might include ensuring the patient takes in an adequate amount of fluids and fibrous foods, while avoiding foods believed to cause diarrhea.
- If or when it is feasible, devise a schedule for regular stool elimination. Where possible, nurses can use a patient's previous routines or patterns of fecal elimination to help establish such a schedule.
- A suitable stimulus can be provided to assist the patient to the toilet. Stimulation can include digital methods, suppository-type stimulation, pulsed evacuation or “irrigation” enema, or “mini-enemas.”
Stimulated and scheduled toileting programs rely on a chemical or mechanical stimulus and stool consistency since these cause the rectum to contract (in a bolus-style movement) and expel fecal matter.
- An exercise regime or program should be arranged for patients with pelvic muscle pseudodyssynergia or sphincter dysfunction/incompetence as a way of retraining, re-educating, and strengthening their pelvic floor muscles. Patients with bowel incontinence caused by a sphincter disorder should be referred to a nursing specialist or to an appropriate therapist who has the clinical knowledge to provide or recommend an appropriate care program. Re-education of the pelvic muscles - where some techniques include exercise, biofeedback, and relaxation of these muscles - is an effective and safe form of treatment for people who suffer bowel incontinence due to conditions and/or dysfunctions mentioned above.
- Nurses should start a biofeedback re-education program for patients with weakened pelvic floor muscles and who suffer bowel incontinence and feel an urgent need to defecate because of recurring diarrhea. Biofeedback and other re-education programs for the pelvic muscles are known to reduce instances of uncontrolled stool loss among people who suffer from diarrhea and urgency sensations where these factors provoke stool incontinence. A reduction in diarrhea frequency can contribute to a reduction in incontinency conditions.
- The skin of the perianal and perineal area should be cleansed after every stool incontinency episode. In cases of frequent leakages, the patient or their carer should use a cleaning product made especially for this purpose. The integrity of the skin around the perianal area can be compromised by frequent cleansing with water and soap, thereby increasing any irritation that results from frequent leakages.
- Where incidents of fecal leakage occur frequently, a mineral-based oil or an agent or ointment with a petroleum base should be applied to the skin around the perianal area. Products of this type protect the skin with a chemical and moist barrier that can reduce or prevent its integrity being compromised by severe leakage or incontinence.
- There are devices available for helping to contain occasional leakages of this type, and nurses can help patients choose a suitable device. These devices help lessen leakage odors and they prevent the patient's clothing from being soiled.
- Patients with reduced mobility who suffer frequent bouts of stool incontinence and/or those who care for them can be taught to keep a regular check on the perineal and scrotal area for signs of pressure ulcers. Regular and routine cleaning, the application of techniques designed to reduce pressure, and effective management of both urinary and fecal incontinence can reduce these risks.
- In the event an incontinence patient or their carer is thinking of using an anal plug, a physician should be consulted. These devices are capable of eliminating or reducing persistent loss of liquid and/or solid fecal matter in some patients.
- Where a patient suffers frequent bouts of stool incontinence, a fecal pouch can be used. These pouches are devices for containing fecal dribbling or loss, reducing odor, and protecting the perianal area from the chemical friction or irritation that can occur when stool comes into contact with the skin.
- Similarly, in cases of severe incontinence, a physician should be consulted about the possibility of using rectal tubes. In cases of severe incontinence and where the integrity of skin around the perianal area has been severely compromised, patients have used a large French-made catheter (the indwelling variety) for containment purposes. How, how safe these devices are is not yet known.
Care for Elder/Geriatric Patients
- A special nursing care plan for incontinence should be devised for elderly patients. When these patients enter a long-term or intensive care unit, they should be evaluated for signs of incontinence. Nurses should intervene as recommended. Incontinence rates of 3% have been reported in facilities that provide intensive care and up to as much as 50% in facilities that provide long-term care for elderly patients.
- The NEECHAM scale can be used to evaluate confusion levels and the cognitive condition of elderly patients. This method identifies acute changes to a person's cognitive state. There are also other tools available for this purpose including the Folstein Mini-Mental Status and nursing staff should choose the most appropriate method. The chance of fecal leakage is increased in elderly people with existing or acute dementia.
Interventions in Cases Where Patients are Cared for at Home
- Assess the patient's continence status, choose a program for managing incontinence, and educate the patient in these techniques.
- Provide the patient with non-restrictive clothing - clothes that are easy to change and easy to manipulate for toileting purposes. Toileting or defecation programs have a better chance of success when complex maneuvers are avoided, and this reduces the risk the patient becoming embarrassed by episodes of incontinence.
- Help families arrange care so that the patient is able to take part in their favorite or usual activities or in family activities without the risk of incidents that might embarrass them. If things are planned carefully, the patient can maintain their dignity and families can maintain their usual routines.
- Thisincontinence care plan example also makes provision for patients who are confined to a chair or bed. Firstly, these patients should be provided with a bedpan or commode that they can easily get to. Where appropriate, the patient should be referred to a suitable service provider for physical training or therapy to be taught side transfer techniques. Such therapy also helps patients build up strength for side and other transfer maneuvers.
- In cases where the patient suffers frequent incontinence, it is possible to seek additional home care services to help the patient with essential hygiene and the care of their skin.
Education of Patients and Their Families
- A bowel incontinence re-education or training program can be arranged for patients and their families. This program should be of a stimulated and scheduled nature, or other programs or strategies can be devised for managing bowel incontinence.
- Patients and their families can be taught about dietary issues i.e. fiber sources, fiber supplements, and/or bulking-up products as appropriate.
- Fellow nursing staff and other caregivers outside the nursing profession can be taught or trained in the provision of basic care such as arranging a toileting schedule and ensuring that patients in long-term or intensive care facilities are given an adequate amount of privacy.
- Further information about managing Constipation and Diarrhea and other related ailments and conditions is provided in a separate fact sheet.