Nursing Diagnosis: Bowel incontinence Application of NANDA, NOC, NIC

Nursing Diagnosis: Bowel incontinence
Mikel Gray

NANDA Definition: Change in normal bowel habits characterized by involuntary passage of stool.

Defining Characteristics: Constant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognizes rectal fullness but reports inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate, red perianal skin

Related Factors: Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Bowel Continence

·         Bowel Elimination

Client Outcomes

·         Regular, complete evacuation of fecal contents from the rectal vault (pattern may vary from every day to every 3 to 5 days) (Roig et al, 1993)

·         Defecates soft-formed stool

·         Decreased or absence of bowel incontinence incidences

·         Intact skin in the perianal/perineal area

·         Demonstrates the ability to isolate, contract, and relax pelvic muscles (when incontinence related to sphincter incompetence, pseudodyssynergia) Increases pelvic muscle strength (when incontinence related to sphincter incompetence)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Bowel Incontinence Care

·         Bowel Training

·         Bowel Incontinence Care: Encopresis

Nursing Interventions and Rationales

·         In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, and aggravating and alleviating factors. Unless questioned directly, patients are unlikely to report the presence of fecal incontinence (Schultz, Dickey, Skoner, 1997). The nursing history determines the patterns of stool elimination to characterize involuntary stool loss and the likely etiology of the incontinence (Norton, Chelvanaygam, 2000).

·         Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual acuity). A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of functional status on stool elimination patterns and incontinence (Gray, Burns, 1996).

·         Complete an assessment of cognitive function. Dementia, acute confusion, and mental retardation are risk factors for fecal incontinence (O'Donnel et al., 1992; Norton, Chelvanaygam, 2000 ).

·         Document patterns of stool elimination and incontinent episodes via a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. This document is used to confirm the verbal history and to assist in determining the likely etiology of stool incontinence. It also serves as a baseline to evaluate treatment efficacy (Norton, Chelvanaygam, 2000).

·         Identify the probable causes of fecal incontinence. Fecal incontinence is frequently multifactorial; therefore identification of the probable etiology of fecal incontinence is necessary to select a treatment plan likely to control or eliminate the condition (Norton, Chelvanaygam, 2000).

·         Improve access to toileting:

• Identify usual toileting patterns among persons in the acute care or long term care facility and plan opportunities for toileting accordingly.
• Provide assistance with toileting for patients with limited access or impaired functional status (e.g., mobility, dexterity, access).
• Institute a prompted toileting program for persons with impaired cognitive status (e.g., retardation, dementia).
• Provide adequate privacy for toileting.
• Respond promptly to requests for assistance with toileting.

Acute or transient fecal incontinence frequently occurs in the acute care or long term care facility because of inadequate access to toileting facilities, insufficient assistance with toileting, or inadequate privacy when attempting to toilet (Gray, Burns, 1996; Ouslander, Snelle, 1995; Wong, 1995).

·         For the client with intermittent episodes of fecal incontinence related to acute changes in stool consistency, begin a bowel reeducation program consisting of:

o   Cleansing the bowel of impacted stool if indicated.

o   Normalizing stool consistency by adequate intake of fluids (30ml/kg of body weight/day) and dietary or supplemental fiber.

o   Establishing a regular routine of fecal elimination based on established patterns of bowel elimination (patterns established before onset of incontinence).

Bowel reeducation is designed to reestablish normal defecation patterns and to normalize stool consistency to reduce or eliminate the risk of recurring fecal incontinence associated with changes in stool consistency (Doughty, 1996).

·         Begin a prompted defecation program for the adult with dementia, mental retardation, or related learning disabilities. Prompted urine and fecal elimination programs have been shown to reduce or eliminate incontinence in the long term care facility and community settings (Doughty, 1996; Ouslander, Snelle, 1995; Smith et al, 1994).

·         Begin a scheduled stimulation defecation program, including the following steps, for persons with neurological conditions causing fecal incontinence:

• Before beginning the program, cleanse the bowel of impacted fecal material.
• Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
• Whenever feasible, determine a regular schedule for bowel elimination (typically every day or every other day) based on previous patterns of bowel elimination.
• Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may be used.

The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material (Doughty, 1996; Dunn, Galka, 1994; King, Currie, Wright, 1994; Munchiando, Kendall, 1993).

·         Begin a pelvic floor reeducation or muscle exercise program for persons with sphincter incompetence or pseudodyssynergia of the pelvic muscles, or refer persons with fecal incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, including biofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with fecal incontinence related to sphincter or pelvic floor muscle dysfunction (Arhan et al, 1994; Enck et al, 1994; Keck et al, 1994; McIntosh et al, 1993).

·         Begin a pelvic muscle biofeedback program among patients with urgency to defecate and fecal incontinence related to recurrent diarrhea. Pelvic muscle reeducation, including biofeedback, can reduce uncontrolled loss of stool among persons who experience urgency and diarrhea as provacative factors for fecal incontinence (Chiarioni et al, 1993). Reducing the incidence of diarrhea can help to reduce bowel incontinence (Bliss et al, 2000).

·         Cleanse the perineal and perianal skin following each episode of fecal incontinence. When incontinence is frequent, use an incontinence cleansing product specifically designed for this purpose. Frequent cleaning with soap and water may compromise perianal skin integrity and enhance the irritation produced by fecal leakage (Byers et al, 1995; Lyder et al, 1992).

·         Apply mineral oil or a petroleum based ointment to the perianal skin when frequent episodes of fecal incontinence occur. These products form a moisture and chemical barrier to the perianal skin that may prevent or reduce the severity of compromised skin integrity with severe fecal incontinence (Fiers, Thayer, 2000).

·         Assist the patient to select and apply a containment device for occasional episodes of fecal incontinence. A fecal containment device will prevent soiling of clothing and reduce odors in the patient with uncontrolled stool loss (Fiers, Thayer, 2000).

·         Teach the caregivers of the patient with frequent episodes of fecal incontinence and limited mobility to regularly monitor the sacrum and perineal area for pressure ulcerations. Limited mobility, particularly when combined with fecal incontinence, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary incontinence reduces this risk (Johanson, Irizarry, Doughty, 1997; Schnelle et al, 1997).

·         Consult the physician concerning the use of an anal continence plug for the patient with frequent stool loss. The anal continence plug is a device that can reduce or eliminate persistent liquid or solid stool incontinence in selected patients (Blair et al, 1992).

·         Apply a fecal pouch to the patient with frequent stool loss, particularly when fecal incontinence produces altered perianal skin integrity. Fecal pouches contain stool loss, reduce odor, and protect the perianal skin from chemical irritation resulting from contact with stool (Fiers, Thayer, 2000).

·         Consult the physician concerning the use of a rectal tube for the patient with severe fecal incontinence. A large-sized French indwelling catheter has been used for fecal containment when incontinence is severe and perianal skin integrity significantly compromised (Birdsall, 1986). The safety of this technique remains unknown (Doughty, Broadwell-Jackson, 1993).

Geriatric

·         Evaluate elderly client for established or acute fecal incontinence when client enters the acute or long term care facility; intervene as indicated. The rate of fecal incontinence among patients in acute care facilities is as high as 3%; in long term care facilities the rate is as high as 50% (Egan, Plymad, Thomas, 1983; Leigh, Turnburg, 1982).

·         To evaluate cognitive status in the elderly person, use a NEECHAM confusion scale (Neelan et al, 1992) to identify acute cognitive changes, a Folstein Mini-Mental Status Examination (Folstein, Folstein, 1975), or other tool as indicated. Acute or established dementia increases the risk of fecal incontinence among elderly persons.

Home Care Interventions

·         Assess and teach a bowel management program to support continence.

·         Provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease. Avoidance of complicated maneuvers increases the chance of success in toileting programs and decreases the client's risk for embarrassing incontinent episodes.

·         Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Careful planning can both help client retain dignity and maintain integrity of family patterns.

·         If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. If necessary, refer the client to physical therapy services to learn side transfers and to build strength for transfers.

·         If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care.

Client/Family Teaching

·         Teach the client and family to perform a bowel reeducation program; scheduled, stimulated program; or other strategies to manage fecal incontinence.

·         Teach the client and family about common dietary sources of fiber, as well as supplemental fiber or bulking agents as indicated.

·         Refer the family to support services to assist with in-home management of fecal incontinence as indicated.

·         Teach nursing colleagues and nonprofessional care providers the importance of providing toileting opportunities and adequate privacy for the patient in an acute or long term care facility.

·         Refer to nursing diagnoses Diarrhea and Constipation for detailed management of these related conditions.