Nursing Dx

Bowel Incontinence

Taxonomy II: Elimination—Class 2 Gastrointestinal System (00014)
[Diagnostic Division: Elimination]
Submitted 1975; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998
Definition: Change in normal bowel habits characterized by involuntary passage of stool

Related Factors
Self-care deficit—inefficient toileting; impaired cognition; immobility; environmental factors (e.g., inaccessible bathroom)
Dietary habits; medications; laxative abuse
Stress
Colorectal lesions
Incomplete emptying of bowel; impaction; chronic diarrhea
General decline in muscle tone; abnormally high abdominal or intestinal pressure
Impaired reservoir capacity
Rectal sphincter abnormality; loss of rectal sphincter control; lower/upper motor nerve damage

Defining Characteristics
SUBJECTIVE
Recognizes rectal fullness but reports inability to expel formed stool
Urgency
Inability to delay defecation
Self-report of inability to feel rectal fullness
OBJECTIVE
Constant dribbling of soft stool
Fecal staining of clothing and/or bedding
Fecal odor
Red perianal skin
Inability to recognize/inattention to urge to defecate

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of causative/controlling factors.
• Identify individually appropriate interventions.
• Participate in therapeutic regimen to control incontinence.
• Establish/maintain as regular a pattern of bowel functioning as possible.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify pathophysiological factors present (e.g., multiple sclerosis, acute/chronic cognitive impairment, spinal cord injury, stroke, ileus, ulcerative colitis).
• Note times/aspects of incontinent occurrence, preceding/ precipitating events.
• Check for presence/absence of anal sphincter reflex or impaction, which may be contributing factors.
• Review medication regimen for side effects/interactions.
• Test stool for blood (guaiac) as appropriate.
• Palpate abdomen for distention, masses, tenderness.
NURSING PRIORITY NO. 2. To determine current pattern of elimination:
• Note stool characteristics (color, odor, consistency, amount, shape, and frequency). Provides comparative baseline.
• Encourage client or SO to record times at which incontinence occurs, to note relationship to meals, activity, client’s behavior.
• Auscultate abdomen for presence, location, and characteristics of bowel sounds.
NURSING PRIORITY NO. 3. To promote control/management of incontinence:
• Assist in treatment of causative/contributing factors (e.g., as listed in the Related Factors and Defining Characteristics).
• Establish bowel program with regular time for defecation; use suppositories and/or digital stimulation when indicated. Maintain daily program initially. Progress to alternate days dependent on usual pattern/amount of stool.
• Take client to the bathroom/place on commode or bedpan at specified intervals, taking into consideration individual needs and incontinence patterns to maximize success of program.
• Encourage and instruct client/caregiver in providing diet high in bulk/fiber and adequate fluids (minimum of 2000 to 2400 mL/day). Encourage warm fluids after meals. Identify/ eliminate problem foods to avoid diarrhea/constipation, gas formation.
• Give stool softeners/bulk formers as indicated/needed.
• Provide pericare to avoid excoriation of the area.
• Promote exercise program, as individually able, to increase muscle tone/strength, including perineal muscles.
• Provide incontinence aids/pads until control is obtained.
• Demonstrate techniques (e.g., contracting abdominal muscles, leaning forward on commode, manual compression) to increase intra-abdominal pressure during defecation, and left to right abdominal massage to stimulate peristalsis.
• Refer to ND Diarrhea if incontinence is due to uncontrolled diarrhea; ND Constipation if diarrhea is due to impaction.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Review and encourage continuation of successful interventions as individually identified.
• Instruct in use of laxatives or stool softeners, if indicated, to stimulate timed defecation.
• Identify foods that promote bowel regularity.
• Provide emotional support to client and SO(s), especially when condition is long-term or chronic.
• Encourage scheduling of social activities within time frame of bowel program as indicated (e.g., avoid a 4-hour excursion if bowel program requires toileting every 3 hours and facilities will not be available) to maximize social functioning and success of bowel program.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Current and previous pattern of elimination/physical findings, character of stool, actions tried.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s/caregiver’s responses to interventions/teaching and actions performed.
• Changes in pattern of elimination, characteristics of stool.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Identified long-term needs, noting who is responsible for each action.
• Specific bowel program at time of discharge.