Get to know the nursing care plan and management for patients with bowel incontinence in this guide. Learn about the nursing assessment, nursing diagnosis, goals, and interventions for fecal incontinence.
Table of Contents
- What is bowel/fecal incontinence?
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- 1. Restoring Bowel Function
- 2. Maintaining or Improving Skin Integrity
- 3. Increasing Self-Esteem and Decreasing Social Isolation
- 4. Preventing Complications
- 5. Client and Caregiver Education
- Recommended Resources
- See also
- References and Sources
What is bowel/fecal incontinence?
Bowel incontinence, also known as fecal incontinence, is the inability to control bowel movements, causing stool to leak unexpectedly from the rectum. It may occur as a result of damage to nerves or muscles and other structures associated with normal elimination or as a result of diseases that change the normal function of defecation.
True anal incontinence is the loss of anal sphincter control leading to unwanted or untimely release of feces or gas. This must be distinguished from other conditions that lead to stool passing through the anus. Fecal urgency also must be differentiated from fecal incontinence because urgency may be related to medical problems other than anal sphincter disruption (Ferzandi & Strohbehn, 2023).
Common factors that lead to bowel incontinence are an injury to rectal, anal, or nerve tissue from trauma, childbirth, radiation, or surgery. Infection with resultant diarrhea or neurological diseases such as stroke, multiple sclerosis, and diabetes mellitus can also result in bowel incontinence. Bowel incontinence may also occur in older adults with dementia and may also occur with age.
The prevalence of fecal incontinence is difficult to estimate because often, this condition is underreported due to social stigma. The overall reported prevalence of fecal or bowel incontinence ranges from 2% to 21%. The prevalence is reported as 7% in women younger than 30 years which rises to 22% in their seventh decade. In older adults, prevalence is reported as high as 25% to 35% of nursing home residents and 10% to 25% of hospitalized clients. Bowel incontinence is the second leading cause of nursing home placement in the older adult population (Roland, 2022).
It is vital for nurses to learn and understand the cause of bowel incontinence because its treatment depends on the cause. Moreover, loss of bowel continence is an uncomfortable situation that should be given attention and importance to avoid social isolation. Appropriate management such as reestablishing a continent bowel elimination pattern and preventing loss of skin integrity may influence the condition of the client and may aid in regaining an individual’s self-esteem.
Nursing Care Plans and Management
Nursing care plans play an essential role in the management of clients with bowel incontinence. These care plans involve a systematic and collaborative approach, aimed at promoting client comfort, preventing complications, and restoring self-esteem. The ultimate goal is to help clients regain control over their bowel function and enhance their quality of life.
Nursing Problem Priorities
The following are the nursing priorities for clients with bowel incontinence:
- Bowel function. Management strategies aimed to establish regular bowel routines and promote healthy bowel habits.
- Skin integrity. Prolonged exposure to fecal matter can lead to skin breakdown and the development of pressure injuries or skin infections.
- Social isolation and decreased self-esteem. Addressing the client’s emotional well-being, providing counseling, and fostering support systems are essential in minimizing the feelings of isolation and embarrassment of a client with bowel incontinence.
- Altered body image. Bowel incontinence can significantly impact a client’s body image. Promoting positive coping strategies can help clients develop and positive body image and improve their self-esteem.
- Physiological complications. Infection and fluid and electrolyte imbalance can occur in clients with bowel incontinence. Monitoring the client’s hydration status, implementing effective infection control, and dietary modifications are important for preventing these complications.
- Client and caregiver education. Educating the client and caregivers/family members about this condition and ensuring that the client’s home care is efficient and effective can help improve the client’s and caregiver’s quality of life.
A detailed neurological exam should be performed for neurological disease. A detailed rectal exam is key in the evaluation of bowel incontinence; it can be best divided into four steps: inspection, anal wink reflex, digital rectal exam, and assessing the anal muscle tone. However, the accuracy of the rectal exam and evaluation of various structures depends to a large extent on the examiner’s experience (Roland, 2022).
Assess for the following subjective and objective data:
- Fecal seepage. Undesired leakage of a stool after a bowel movement with otherwise normal continence and evacuation.
- Urge incontinence. Discharge of feces and flatus in spite of active attempts to retain these contents.
- Passive incontinence. Involuntary passage of feces and flatus without any awareness.
- Encopresis. A term used mostly for fecal incontinence in children.
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with bowel incontinence based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes for bowel incontinence may include:
- The client is continent of stool or reports decreased episodes of bowel incontinence.
- The client participates in a daily bowel program until a bowel pattern develops.
- The client evacuates a soft, formed stool.
- The client verbalizes feelings of self-control regarding bowel movements.
- The client verbalizes ways how to keep bowel movements regular by naming what foods to eat and how much fluids to intake.
Nursing Interventions and Actions
Therapeutic nursing interventions and actions for clients with bowel incontinence may include:
1. Restoring Bowel Function
Restoring bowel function in clients with bowel incontinence requires a comprehensive approach that addresses the underlying causes and helps the client regain control over their bowel movements. Specific interventions may vary depending on the client’s condition, and the following are some strategies that can be employed to restore normal function.
Assess ability to participate in bowel continence
Identify the cause of incontinence.
This information serves as baseline data and provides direction for subsequent interventions. Other clients have more than one contributing factor. Stool seepage that produces soiling of undergarments may result from hemorrhoids, enlarged skin tags, poor hygiene, fistula-in-ano, and rectal mucosal prolapse. Other conditions that result in poor bowel control are inflammatory bowel disease, laxative abuse, parasitic infection, and toxins (Ferzandi & Strohbehn, 2023).
Assess the client’s normal bowel elimination pattern.
Every individual has a unique bowel elimination pattern. What’s “normal” for one person may not be normal for another; some have two bowel movements per day, whereas others may have a bowel movement infrequently as every third or fourth day. Most people feel the urge to defecate soon after the first oral intake of the day such as coffee or breakfast; this is a result of the gastrocolic reflex.
Determine the course of medications or treatments that may contribute to bowel incontinence.
Uncontrollable explosive diarrhea may be the result of hyperosmolar tube feedings, bowel preparation agents, pelvic and abdominal irradiation, some chemotherapeutic agents, and certain antibiotic agents. There are reports of antipsychotic-induced incontinence in the literature. The highest is associated with clozapine. Anecdotal observations with other atypical antipsychotics like olanzapine, asenapine, and risperidone have also been made (Singh et al., 2019).
Perform manual checkup for fecal impaction.
Liquid stool may leak past the impaction when the client has a hard, dry stool that cannot be expelled normally. Occasionally, clients may also present with spurious or overflow diarrhea. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger (Setya et al., 2022).
Assist in preparing the client for several tests.
These procedures are performed to determine the causes of bowel incontinence. Tests include flexible sigmoidoscopy, barium enema, colonoscopy, and anal manometry (study to determine the function of rectal sphincters). Diagnostic testing is guided by whether incontinence is related to stool consistency. If incontinence is without any diarrhea then more specific testing should be pursued (Roland, 2022).
Assess the use of diapers, sanitary napkins, incontinence briefs, fecal collection devices, and underpads.
Clients or caregivers may use well-known products such as sanitary napkins to collect fecal material and for protection from bowel leaks, especially at night. Absorbent pad products come in a range of brands, sizes, shapes, and absorbencies, and are generally unisex. Too high an absorbency, or insufficient absorbency, can cause skin damage (Yates, 2017).
Evaluate the ability of the client to go to the bathroom independently.
Rearranging the environment can prevent soiling accidents that can happen with the client’s inability to get to the bathroom. It also helps determine the client’s level of mobility, coordination, and overall physical capability. This evaluation assists the healthcare professionals in identifying any limitations or challenges the client may face in accessing the bathroom.
Assess the female client’s obstetric history.
An obstetric history should be taken carefully. Information about the number of vaginal deliveries and the presence of any risk factors for fecal incontinence pertaining to those deliveries should be obtained. A prolonged second stage of labor, forceps delivery, significant tears, and episiotomy, among other causes, are associated with an increased risk for anal sphincter disruption and pudendal nerve injury (Ferzandi & Strohbehn, 2023).
Utilize fecal incontinence survey tools for assessment.
Several fecal incontinence surveys attempt to quantify and qualify the severity of fecal incontinence. Two examples are the Fecal Incontinence Quality of Life Scale and the Fecal Incontinence Questionnaire. The forms are largely designed as outcome measures and are most useful because of a great deal of information about client symptoms and the impact of those symptoms on the client in a short period of time (Ferzandi & Strohbehn, 2023).
Assess the rectal area
Assess for the presence of the anal wink reflex.
This can be done by gently stroking the perianal skin with a cotton bud which will cause brisk contraction of the external anal sphincter. The absence of this reflex indicates a loss of spinal arc and possibly underlying neurological disease (Roland, 2022).
Assist during a digital rectal examination, as indicated.
A digital rectal examination should be performed to detect obvious anal pathology and provide an initial assessment of the anal resting tone. As the examiner is beginning the rectal examination, resistance is met at the anal verge. If the examining finger meets little resistance and the anus feels patulous, significant sphincter dysfunction may be present (Ferzandi & Strohbehn, 2023).
Assess the resting rectal tone and the pelvic floor muscles.
During the digital rectal exam, a resting rectal tone should be assessed to evaluate the internal anal sphincter. After this, the client should be asked to bear down during which the function of the puborectalis (to straighten the anorectal angle), as well as pelvic floor muscles, can be assessed. Finally, the client may be asked to squeeze during which increased pressure due to the contraction of the external anal sphincter is felt (Roland, 2022).
Medical management of bowel incontinence
Perform removal of fecal impaction manually, if necessary.
The presence of fecal impaction can interfere with the establishment of a regular bowel routine. This is a helpful procedure if one can palpate hard stool in the rectal area. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger. Sometimes the procedure can be aided by an anoscope and suction (Setya et al., 2022).
Keep bedside commode and assistive device on sight.
Immediate access to appropriate toileting facilities reduces unnecessary “accidents.” clients with fecal incontinence describe spending a significant amount of time planning for and worrying about accidents. Time is also a significant issue because of the worsening of symptoms with aging and trying to maintain a work-life with symptoms of fecal incontinence (Peden-McAlpine et al., 2018).
Assist the client with mobility or exercise, if tolerated.
Movement and exercise stimulate peristalsis and aid in bowel movement. Multiple studies have linked pelvic floor activation with concomitant activity of the abdominal musculature with pelvic floor activity known to be associated with lifting tasks, spinal stabilization, and functional tasks such as head and shoulder raising as well. This suggests that the pelvic floor musculature and the muscles of the rest of the body function as an integrated unit such that overall physical activity may benefit the pelvic floor as well (Staller et al., 2018).
Create a bowel training program
Promoting regular time for bowel elimination prevents the bowel from emptying sporadically. The goals of a bowel training program are to develop regular bowel habits and to prevent uninhibited bowel elimination. Interventions may include:
Encourage bowel elimination at the same time each day.
Soon after breakfast is the best time because the gastrocolic reflex is stimulated by food or fluid intake. Regular, complete emptying of the lower bowel results in bowel continence. A regular time for defecation is established, and attempts at evacuation should be made within 15 minutes of the designated time daily.
After breakfast or a warm drink, or before the scheduled elimination time, administer a suppository and perform digital stimulation every 10 to 15.
For some cases, direct stimulation of the rectal sphincter and lower colon may be needed to initiate peristalsis. The anorectal reflex may be stimulated by a rectal suppository or by mechanical stimulation. Mechanical stimulation should only be used in clients with a disability who have no voluntary motor function and no sensation as a result of injuries above the sacral segments of the spinal cord, such as clients diagnosed with quadriplegia, high paraplegia, or severe brain injuries. The technique is not effective in clients who do not have an intact sacral reflex arc.
Place the client in an upright or squatting position for defecation.
Sitting upright with feet flat on the floor promotes muscular movement that aids in defecation. The client may also assume the normal squatting position and be in a private room for defecation if at all possible. The upright or squatting position encourages a straighter alignment of the rectum, which allows for more complete emptying of the bowels. These positions can also promote relaxation of the pelvic floor muscles, allowing for easier passage of stool and reducing straining associated with bowel movements.
Discourage the use of pads, diapers, or collection devices for long-term management of bowel incontinence.
These products can be used on a short-term basis to prevent soiling but may irritate the skin in the long run. Prolonged periods of wetness can be a cause of skin irritation due to diaper rash. This may occur if diaper changes are left for a long time. Chafing can also occur when the material rubs against the skin causing friction, or when the folds of the skin stick to each other for a prolonged period of time (National Association for Continence, 2022).
Using fecal collection systems
Use fecal collection systems or bowel management systems selectively over pads and diapers.
These devices allow for the collection and disposal of stool without exposing the perianal skin to stool; odor and embarrassment are controlled because the stool is contained. The use of these collection systems may also reduce cross-contamination in clients with C. difficile. These devices may result in cost savings due to less use of linens, fewer nursing time requirements, and fewer client complications (Arndt, 2020). These may include the following:
External anal pouch.
This consists of a bendable wafer that has an opening at its center. One side of the wafer adheres to the skin around the anus and the other side is connected to a collection bag. These devices have a drainable pouch attached to the adhesive wafer. If put on properly, a fecal incontinence device may stay in place for 24 hours. It is important to remove the pouch if any stool has leaked because it can irritate the skin. (Mount Sinai, 2022)
Intra-anal stool bag.
This is made of latex (20cm non-extended, 26cm extended) that is inserted into the anus and an adhesive attachment (10cm in diameter) is applied around the anus to secure it in position. Application of the containment device usually requires a pair of experienced physicians, advanced practice nurses, or other healthcare professionals to correctly position the client and apply the device correctly (Arndt, 2020).
Rectal tubes and catheters.
These are inserted into the rectum to direct loose stool into a collection bag. A balloon near the tip of the catheter (inside the body) can be inflated once the catheter is in position to block leakage of stool around the catheter and to prevent the tube from coming out throughout a bowel movement. Water or a normal saline solution may be used to inflate the balloon and hold the device in place (Arndt, 2020).
The trumpet is made up of a nasopharyngeal airway connected to a drainage bag. The flange (wide) end of the trumpet is inserted into the rectum. A trumpet is shorter than a rectal tube so there is less chance of damaging the lining of the rectum. The other narrow end of the trumpet can be connected to a drainage bag. It has been shown to increase nursing satisfaction and decrease incontinence-associated dermatitis without influencing pressure injury rates. It was described as being easier and faster to place than traditional adhesive pouches. However, rectal trumpets can cause rectal hemorrhage that results in PRBC transfusions, hypotension, and the need for invasive procedures (Glass et al., 2018).
Administer medications as prescribed.
The goal of medical therapy is to reduce stool frequency and improve stool consistency. This involves the administration of laxatives, bulking agents, and antimotility medications.
- Bulk-forming laxatives
These agents retain fluid in the stool and increase stool weight and consistency. Psyllium, dietary fiber, and methylcellulose are common examples. It is important to take ample amounts of water for bulk-forming agents to work (Bashir & Sizar, 2022).
- Antimotility agents
In clients with diarrhea due to noninfectious etiologies or with reduced rectal compliance due to radiation proctitis or inflammatory bowel disease, agents that slow the motility of the gut may be helpful. Loperamide hydrochloride increases gut transit time, allowing for increased absorption of water from the volume of stool. This results in a firmer, more easily controlled stool. The usual dose regimen is 2 to 4 mg twice or three times daily to control symptoms (Ferzandi & Strohbehn, 2023).
Assist the client during the biofeedback procedure.
Biofeedback is a safe, minimally invasive behavioral technique that uses auditory or visual feedback to reeducate the pelvic floor musculature. The most commonly used techniques are rectal sensitivity training and anal sphincter strength training (Ferzandi & Strohbehn, 2023).
Surgical management of bowel incontinence
Prepare the client for surgical management procedures and assist in these procedures as appropriate.
Once medical therapy has been maximized, minimally invasive and surgical therapies may be considered. The type of procedure used is based on the client’s history, physical examination findings, and results of the diagnostic evaluation (Ferzandi & Strohbehn, 2023). These procedures may include the following:
This procedure consists of dissecting out the external anal sphincter, dividing the scar tissue in the midline, and then overlapping the scar so that muscle is approximated to muscle as closely as possible. Several postoperative studies have demonstrated improvement in resting and squeeze pressures (Ferzandi & Strohbehn, 2023).
Sacral nerve stimulation
This is a minimally invasive approach for fecal incontinence. The stimulator may benefit clients with minor anal sphincter deficits due to a neurological issue. The stimulation decreases symptoms of fecal incontinence by enhancing the squeeze and resting anal pressures and colonic motility (Roland, 2022).
Internal anal sphincter repair
This surgical approach requires dissection along the intersphincteric plane and identification of the internal anal sphincter. According to a study, continence scores improved in all clients who underwent the repair, and two clients achieved complete continence (Ferzandi & Strohbehn, 2023).
Some researchers perform the postanal repair in clients with anal incontinence from a neurogenic or idiopathic cause. Clients have decreased ability to sense impending defecation and may initially become aware of the need for a bowel movement only after they have passed stool and notice the odor or sensation of fecal material around the anus. The original theory behind postanal repair was the restoration of the anorectal angle and lengthening of the anal canal (Ferzandi & Strohbehn, 2023).
Injection of anal bulking agent
Another relatively new method to manage fecal incontinence is the use of an injectable anal bulking agent. The hyaluronic acid derivative is injected into the anal mucosa and the treatment can be repeated. Early results show that some clients may have a reduction in episodes of fecal incontinence (Roland, 2022).
Artificial bowel sphincter
The artificial bowel sphincter was designed to act as a client’s own anal sphincter in cases of severe fecal incontinence. This implantable device is produced by American Medical Systems and is available in the United States. The inflatable cuff is placed around the anus, and an inflation reservoir is placed in the space of Retzius. As the client feels the need to have a bowel movement, a control pump is squeezed and forces water out of the cuff. This allows the client to have a bowel movement (Ferzandi & Strohbehn, 2023).
Vaginal bowel control device
The Eclipse System offers a conservative, safe, and effective option for the management of fecal incontinence with no reported serious adverse outcomes, it is a vaginal insert that is intended to treat fecal incontinence in women 18 to 75 years old who experience at least four incontinence episodes in a 2-week period. The device includes an inflatable balloon, which is placed in the vagina. Upon inflation, the balloon exerts pressure through the vaginal wall onto the rectal area, thereby reducing the number of fecal incontinence episodes (Ferzandi & Strohbehn, 2023).
When fecal incontinence persists after medical and surgical therapies have failed, a colostomy may be considered. This converts a perineal stoma into a manageable abdominal stoma and removes the constant fear of public humiliation.
Institute the necessary postoperative dietary restrictions as indicated.
Specific dietary restrictions are commonly used postoperatively. Many surgeons delay feeding and keep clients on clear liquid diets or soft foods for several days. Others allow a more liberal diet and use stool softeners and mineral oil to decrease stool firmness (Ferzandi & Strohbehn, 2023).
Arrange for a follow-up four to six weeks after the procedure.
Postoperative evaluation should be scheduled for four to six weeks after the procedure. At this time, most postoperative swelling and tissue distortion are usually resolved. A history of the client’s bowel habits should be taken and problems addressed. Owing to the nature and location of the surgical repair, pain control is an important issue. The client should have adequate access to their surgeon for additional medications as necessary (Ferzandi & Strohbehn, 2023).
2. Maintaining or Improving Skin Integrity
Prolonged exposure to fecal matter can lead to skin breakdown and the development of pressure injuries. Preventing and managing skin problems by maintaining proper hygiene, using protective barriers, and implementing regular skin assessments are nursing priorities.
Performing skin assessment
Inspect the client’s skin.
Inspect the client’s skin, including perigenital skin, noting color, turgor, moisture, temperature, and the presence or absence of skin injuries. Adequate lighting will help see any subtle changes in skin color. Repeat skin assessments as needed. Clients who are incontinent should be assessed more frequently because they are at increased risk for IAD (Francis, 2018).
Assess perineal skin integrity.
The stool can create chemical sensitivity to the skin, which may be worsened by the use of diapers, incontinence briefs, and underpads. The main skin condition associated with incontinence is incontinence-associated dermatitis (IAD), also known as moisture lesions/ulcers, irritant dermatitis, diaper/nappy rash, or perineal rash (Yates, 2017).
Assess for signs and symptoms of incontinence-associated dermatitis (IAD).
Recognizing IAD depends on certain characteristics being present, such as pain, burning, itching, or tingling, blotchy or poorly defined edges of the affected area, kissing ulcer, and intact skin with erythema with or without superficial partial-thickness skin loss. Secondary superficial skin infections such as candidiasis may be present (Yates, 2017).
Utilize valid and reliable skin assessment tools.
Assessment is an initial process either to identify the risk of IAD if it had not yet developed or to grade or determine the severity level of the IAD if it is present. The following assessment tools were used in various studies: Incontinence Assessment, IAD Risks Assessment, Skin Damage Assessment, Grade of Skin Damage, IAD Severity Instrument, Ghent Global IAD Categorization Tool, and Skin Moisture Alert Reporting Tool. researchers and experts recommend that healthcare workers should start an assessment to seek for causes of incontinence, risks of IAD, and levels of skin damage before planning to prevent and care for IAD (Banharak et al., 2021).
Management of the risk for skin injuries
Wash the perineal area after each elimination with soap and water. Apply a moisture barrier ointment.
Any fecal material left on the skin may cause irritation, skin excoriation, and pain. This pain may result in fear of defecating and cause the client to deny the urge to defecate. This may result in impaction and eventually bowel incontinence. The skin should be cleansed with a cleanser after each incontinence episode, during/after bathing, and then pat dry. A barrier product may be applied to help protect the skin (Canadian Continence Foundation, 2017).
Use soft, gentle materials when cleaning the perianal area.
Gently clean the skin with a soft cloth and a no-rinse cleansing product that contains surfactants to loosen irritants. Avoid products that require rinsing and drying the skin with a towel because it can cause skin irritation. Choose a soft cloth to limit friction damage to the area and a cleanser with a pH range consistent with the skin’s acid mantle. Another option is an all-in-one soft cloth that contains a cleanser, moisturizer, and barrier. Some evidence supports the use of all-in-one products because they are easier to use and ensure all three steps are routinely implemented (Francis, 2018).
Avoid hygienic products that can cause skin irritation.
The cleansing products used should not contain alcohol, chemical color, lotion, or perfume/fragrance. Some authors suggested that the pH for skin cleansing should range from 4.0 to 6.8. Soap and warm water, wet cloths and towels, and alkaline soap are not advised. If using soap, liquid soap for children is preferred. Rubbing, wiping, and rinse are actions to be avoided. (Banharak et al., 2021)
Provide appropriate absorbent products as recommended.
Using absorbent products in combination with frequent garment changing will help keep the skin dry and prevent fungal dermatitis. Absorbent incontinence products, such as pads or briefs worn by the client and pads placed on the bed or chair, quickly wick moisture away from the skin to reduce IAD risk. Body-worn briefs should be limited to ambulatory clients to avoid fungal dermatitis that can occur from occlusion of the perineal area in bed-bound clients (Francis, 2018).
Apply skin protectants or barriers after each cleansing.
Place a direct barrier on the skin to prevent direct contact with fecal material. Baby powder and corn starch are not barrier products. Use a barrier that does not have sensitizers such as fragrance or lanolin. There are four main types of skin protectant ingredients found in skin protectants and barriers. These include:
- Petroleum jelly
This is derived from petroleum processing and is a common base for ointments. This forms an occlusive layer, increasing skin hydration; however, it may affect the absorbency of pad products. These products look transparent when applied thinly.
- Zinc oxide
These products can be found in the form of opaque cream, ointment, or paste. Zinc oxide can be difficult and uncomfortable because it can be thick when applied. Additionally, they are opaque creams, which means that they need to be removed for skin inspection.
This type is silicone-based and non-occlusive. It does not affect pad absorption when used sparingly, and can be opaque or transparent.
- Acrylate terpolymer
Polymer forms a transparent film on the skin. It does not require removal because it is transparent and allows for easier skin inspection (Yates, 2017).
Place the client in a position that decreases the area of skin irritation and risk of pressure injury.
Body positioning is a method to decrease the surface area of skin irritation. Placing the client on either the right or left side instead of on the back prevents and decreases the severity of IAD (Banharak et al., 2021). generally, those who experience discomfort after 30 to 60 minutes of lying prone need to be repositioned. The recumbent position is preferred to the semi-Fowler position to decrease the risk of pressure injuries because of the increased supporting body surface area in this position.
Reposition the client frequently or every two hours.
Frequent changes in position are needed to relieve and redistribute the pressure on the client’s skin and to promote blood flow to the skin and subcutaneous tissues. This can be accomplished by instructing the client to change position or by turning and repositioning the client.
Instruct the wheelchair-bound client on how to relieve pressure while sitting.
For clients who spend long periods of time in a wheelchair, the nurse can instruct them on how to relieve pressure. The client can do push-ups, wherein the client pushes down on armrests and raises the buttocks off the seat of the chair. The client may also perform one-half push-ups by repeating the push-up on the right side and then the left, pushing up on one side by pushing down on the armrest. The client may also move from one side to the other side while sitting on the chair, or they can bend forward with the head down between the knees, if able, and constantly shift in the chair.
Place supportive pillows over bony prominences.
Another way to relieve pressure over bony prominences is the bridging technique, accomplished through the correct positioning of pillows. The body can be supported by pillows to allow for space between bony prominences and the mattress. A pillow or commercial heel protector may be used to support the heels off of the bed for the supine client. Placing pillows superior and inferior to the sacrum relieves sacral pressure.
Encourage the client to increase protein-rich food in their diet.
Tissue recovery is faster when supported by nutrient-rich sources, especially protein. A study recommended that foods high in protein should be promoted to both prevent clients from IAD and recover clients who already had IAD for faster wound healing (Banharak et al., 2021).
Utilize pressure-relieving devices as recommended.
Specialty beds or alternative bed surfaces may be indicated to help relieve the pressure on the skin. A client who sits in a wheelchair for prolonged periods should have wheelchair cushions fitted and adjusted on an individualized basis, using pressure measurement techniques as a guide to selection and fitting. Static support devices distribute pressure evenly by bringing more of the client’s body surface into contact with the supporting surface. Gel-type flotation pads and air-fluidized beds reduce pressure. Soft-moisture absorbing padding is also helpful because the softness and resilience of padding provide for more even distribution of pressure and the dissipation and absorption of moisture, along with freedom from wrinkles and friction.
Promote mobility and ROM exercises.
The client is encouraged to remain active and is ambulated whenever possible. When sitting, the client is reminded to change positions frequently to redistribute weight. Active and passive exercises increase muscular, skin, and vascular tone. Turning and exercise schedules are essential for clients at risk for pressure injuries.
3. Increasing Self-Esteem and Decreasing Social Isolation
Clients with fecal incontinence experience significant quality of life issues related to the shame and embarrassment of the physical symptoms of fecal incontinence as well as decreased self-esteem and distorted body image (Peden-McAlpine et al., 2018). Clients who present for evaluation of fecal incontinence usually have had to overcome extreme embarrassment over their condition prior to their office visit. Care should be given to the manner in which the topic is approached in order to promote an open and comfortable discussion (Ferzandi & Strohbehn, 2023).
Assessing the client’s perception of self and body image
Evaluate the extent to which the client’s daily activities are modified by bowel incontinence.
The fear of uncontrolled bowel elimination may result in social isolation. Individuals with bowel incontinence are likely to experience soiling of clothing and embarrassment. Work-life presents complicated situations for both men and women and limits some people’s abilities to engage in productive work outside the home. Women specifically talked about how they postpone business meetings because of their fecal incontinence symptoms (Peden-McAlpine et al., 2018).
Evaluate the surroundings for the availability of an accessible toilet facility.
Lacking access to toileting facilities at home, in the work setting, in the shopping mall, and the like can intensify the incontinence experience. When going into public places immediately seeking out the location and availability of a bathroom is a major consideration. Travel is limited to familiar places, and significant planning is required prior to travel to prevent potential accidents (Peden-McAlpine et al., 2018).
Assess the level of anxiety related to social relationships.
Clients perceive that fecal incontinence is a threat to their social acceptability and privacy and that it affects their relationships. Both men and women suffer from anxiety because of the potential social isolation they may experience because of their symptoms of fecal incontinence. Women have concerns about entering into new relationships because of their fear and shame of possibly having to disclose their fecal incontinence (Peden-McAlpine et al., 2018).
Assess the presence and effect of stigma on the client’s daily life.
Clients with fecal incontinence stigmatize themselves because of their inability to control their symptoms. Women in particular feel shame and unworthiness due to fecal incontinence. Some women report the need for psychological consultations because of feeling inadequate and vulnerable (Peden-McAlpine et al., 2018).
Identify the client’s perception of themselves and their body image.
People with fecal incontinence have negative changes in body image and self-esteem as a result of their inability to control the symptoms of their disease. They perceive that their emotional life and self-confidence are undermined because of their fecal incontinence and embarrassment. (Peden-McAlpine et al., 2018)
Interventions to restore self-esteem
Encourage open communication and provide emotional support.
Low self-esteem is a common psychological consequence of living with bowel incontinence. By encouraging open communication, the nurse creates a safe and non-judgmental environment where the client feels comfortable expressing tier feelings and concerns related to their condition.
Reinforce information about the condition, its causes, and management strategies.
Education plays an essential role in empowering clients and enhancing their self-esteem. By providing information, the nurse helps the client understand that bowel incontinence is a manageable condition and not a personal failure. This knowledge equips the client with a sense of control and fosters self-confidence in managing their symptoms effectively.
Encourage the client to engage in fulfilling activities and hobbies.
Engaging in enjoyable activities can boost self-esteem and improve relationships with others. This also diverts the client’s focus on the challenge of bowel incontinence and promotes a sense of accomplishment and fulfillment. The client may regain a positive outlook in life and a sense of purpose when they participate or renew their interest in things or activities that they love.
Provide positive reinforcement for the client’s effort and progress.
Recognizing and acknowledging the client’s efforts and progress in managing their condition helps instill a sense of accomplishment, self-worth, and confidence. By providing praise and positive feedback, the nurse reinforces the client’s belief in their ability to effectively manage their life and their condition, which can positively impact their self-esteem.
Encourage the client to adopt positive coping strategies.
Clients with fecal incontinence should establish positive coping strategies, such as maintaining hope and optimism by focusing on getting better or reframing fecal incontinence by asserting control. The client may focus on controlling all aspects of their life in relation to fecal incontinence and avoiding accidents. This involves, early in the experience of fecal incontinence, adapting to the presence of obstacles and “making the best of it” (Peden-McAlpine et al., 2018).
Set goals that are meaningful to the client and realistic in terms of their condition.
Positive coping can be tailored by goal setting. The major goals of people experiencing fecal incontinence are specific and individual, such as to have fewer dietary restrictions, less fecal leakage especially during exercise, confidence in controlling fecal incontinence symptoms, and a normal daily routine (Peden-McAlpine et al., 2018).
Promote interventions that can help preserve body image.
Clients with fecal incontinence may preserve their body image by dressing carefully to conceal a possible fecal incontinence accident. Large diaper-like pads are avoided because of their perceived visibility beneath clothing and small, discreet disposable pads are preferred. Wearing dark clothing can help conceal stains if an accident should occur (Peden-McAlpine et al., 2018).
Teach practical strategies to manage fecal incontinence symptoms.
Being prepared is a common theme in discussions related to planning strategies to avoid accidents which include morning bathroom rituals, changing the location of the client’s workstation relative to the bathroom, altering eating habits (food and timing), taking a fiber supplement, or using anti-diarrheal products. The client may pack “kits” of absorbent products, cleansing supplies, and extra clothing as a routine part of planning to leave their home when preparing for an unexpected accident (Peden-McAlpine et al., 2018).
Encourage the client’s family members and friends to offer social support.
Social support from spouses is very important for clients with fecal incontinence. They may attribute their adaptation to fecal incontinence to the loving, empathic, unconditional support they receive from their significant others. Discussing the problems they have experienced due to their condition can be comforting (Peden-McAlpine et al., 2018).
4. Preventing Complications
A relatively high prevalence of continence issues leads to a number of identified complications, such as skin conditions, UTIs, higher risk of falls, constipation, fecal impactions, loss of dependence, and affect the quality of life. Accurate assessment, adequate understanding, and appropriate interventions can help avoid these preventable complications (Yates, 2017).
Assessing for signs of complications
Assess for signs of surgical site infection, bleeding, and hematoma formation.
The risk of infection after surgical procedures or fecal incontinence is 3 to 5%. Observe for signs of swelling, erythema, worsening pain, and fever, which may indicate an infection. Bleeding and hematoma formation can go unnoticed in the perirectal space and result in the sequestration of large amounts of blood (Ferzandi & Strohbehn, 2023).
Assess the severity of the pain.
Pain may be associated with bowel movements and intercourse, leading to a great deal of frustration for both the provider and the client. Undertreated pain can result in mental anguish, depression, anxiety, and overall poor quality of life.
Promote meticulous perineal hygiene and provide guidance on proper cleansing techniques.
Maintaining good perineal hygiene is important in preventing infection in clients with fecal incontinence. The nurse helps minimize the risk of skin breakdown, irritation, and infection by promoting proper, meticulous perineal hygiene. Regular cleansing removes fecal matter, reduces bacterial growth, and maintains skin integrity, thereby preventing potential infections.
Administer antimicrobial prophylaxis for colorectal procedures.
Preoperative antibiotics should be administered prior to beginning the procedure. Oral prophylaxis consists of neomycin plus erythromycin, or neomycin plus metronidazole, started no more than 18 to 24 hours before surgery. A single preoperative dose of antibiotic is sufficient and should be administered within one hour prior to incision (Ferzandi & Strohbehn, 2023).
Ensure wound drainage and collection systems are functioning appropriately.
Opening the wound to allow for drainage and treatment of antibiotics may allow the provider to salvage the surgical repair. Fistula formation occurs in fewer than 1% of the series reviewed, but it is more common in those cases in which infection develops (Ferzandi & Strohbehn, 2023).
Improving hydration and nutrition status
Assess fluid and fiber intake.
Fiber and fluid are great for normalizing bowel function. Eating and diet are significant components of quality of life for clients with fecal incontinence. Regularity, timing, nutrition and fluids, exercise as well as positioning all promote predictable defecation.
Provide a high-fiber diet under the direction of a registered dietician, unless contraindicated.
Insoluble type of fiber promotes the movement of material through the digestive system and increases stool bulk, so it can be of benefit to those who struggle with irregular stools. Bulky stool stimulates peristalsis and expulsion of stool from the bowel. The client’s diet should include foods such as vegetables, fruit, and bran to stimulate peristalsis.
Ensure fluid consumption of at least 2000 to 3000 mL/day, unless contraindicated.
This prevents impaction because a moist stool can move through the bowel more easily. If the client has diarrhea, fluid therapy is vital for volume replacement. Drinking prune juice (120 mL) 30 minutes before a meal once daily is helpful in some cases when impaction is a problem.
Encourage the intake of natural bulking agents to thicken stools, for example, foods such as bananas, rice, and yogurt.
These foods help provide bulk to the stool by absorbing fluids from the stool. Natural bulking agents add bulk and moisture to the stool, resulting in increased stool consistency. This can help regulate bowel movements by promoting the formation of well-formed stools.
5. Client and Caregiver Education
Client and caregiver education in bowel incontinence are necessary for promoting self-management, treatment adherence, and psychosocial well-being. It empowers individuals to actively participate in their care, make informed decisions, and implement strategies to improve bowel control.
Assess the client’s and caregiver’s readiness for self and home care.
When planning the approach to self-care, the nurse must consider the individual client’s knowledge, experience, social and cultural background, level of formal education, and psychological status. The preparation for self-care must also be spread out over the course of the recovery period, and it must be monitored and updated regularly as the client masters aspects of self-care. This is also highly relevant for informal caregivers of the client.
Assess the client’s support system.
When a client is discharged from the facility, informal caregivers, typically family members, often assume the care and support of the client. Therefore, the nurse must assess the client’s support system well in advance of discharge. The positive attitudes of family and friends toward the client, their disability, and the return home are important in making a successful transition to home.
Develop an ADL checklist with the client and their caregiver.
The nurse must develop methods to help the client and family cope with problems that may arise. An ADL checklist individualized for the client and family may ensure that the family is proficient in assisting the client with certain tasks.
Provide written instructions and resources about equipment and how to use them for caregivers.
Family members are taught how to use equipment and are given a copy of the equipment manufacturer’s instruction booklet, names of resource people, lists of equipment-related supplies, and locations where they may be obtained. A written summary is included in family education.
Educate the client and caregiver on the importance of fluid and fiber in maintaining soft, bulky stools.
This improves personal efficacy and can enhance compliance and participation with the therapeutic regimen. Natural bulking agents and high-fiber foods or supplements can add bulk to the stool and stimulate the natural contraction of the colon, facilitating a more predictable and regular bowel movement.
Educate the caregiver on the use of a fecal device, if necessary.
This may be challenging but the caregiver has the chance to learn to manage the device with appropriate guidance and feedback. Client and family discomfort and anxiety may be decreased by education. Discuss the goals of the bowel management program and the expected benefits of the intervention with the client and family too (Arndt, 2020).
Educate the client about proper hygiene and the use of soap and water and moisture barrier containing zinc oxide or dimethicone.
These prevent skin irritation and pain that may lead to fecal impaction and eventually bowel incontinence. Barriers protect the skin from fecal matter. A barrier rather than a moisturizer should be used in the perineal area to prevent skin irritation. They provide a coating on the skin that feces cannot penetrate and some barriers are formulated to help reduce friction from linen, clothing, or incontinence pads (Canadian Continence Foundation, 2017).
Educate the client on the importance of establishing a regular schedule for bowel elimination.
Knowledge helps the client and family understand the rationale for treatment and assists the client in assuming responsibility for self-care later. Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation.
Discuss the use of assistive devices, such as incontinence pads, and provide instructions for proper use.
Assistive devices can be valuable tools in managing fecal incontinence at home. The nurse may enable the client and caregiver to choose and utilize the most appropriate products for their specific needs. Absorbent pads come in a range of brands, sizes, shapes, and absorbencies, therefore, learning about each of them can help the client and caregiver make an informed decision on what to utilize at home (Yates, 2017).
Refer the client to support services and community resources.
A network of support services and communications systems may be required to enhance opportunities for independent living. The nurse uses collaborative, administrative skills to coordinate these activities and pull together the network of care. The nurse also provides skilled care, initiates additional referrals when indicated, and serves as a client advocate and counselor when obstacles are encountered.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
More nursing care plans related to gastrointestinal disorders:
- Bowel Incontinence (Fecal Incontinence)
- Diarrhea Nursing Care Plan and Management
- Cholecystitis and Cholelithiasis
- Gastroesophageal Reflux Disease (GERD)
- Ileostomy & Colostomy
- Inflammatory Bowel Disease (IBD)
- Liver Cirrhosis
- Nausea & Vomiting
- Peptic Ulcer Disease
- Subtotal Gastrectomy
References and Sources
- Arndt, J. V. (2020). 135 Fecal Containment Devices and Bowel Management Systems. Elsevier.
- Banharak, S., Panpanit, L., Subindee, S., Narongsanoi, P., Sanun-aur, P., Kulwong, W., Songtin, P., & Khemphimai, W. (2021). Prevention and Care for Incontinence-Associated Dermatitis Among Older Adults: A Systematic Review. Journal of Multidisciplinary Healthcare, 14.
- Bashir, A., & Sizar, O. (2022). Laxatives – StatPearls. NCBI. Retrieved June 26, 2023, from
- Canadian Continence Foundation. (2017). Skin Care for Urinary and Fecal Incontinence. Canadian Continence Foundation.
- Cheever, K. H., & Hinkle, J. L. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
- Ferzandi, T. R., & Strohbehn, K. (2023, March 9). Fecal Incontinence: Practice Essentials, Background, Pathophysiology. Medscape Reference.
- Francis, K. (2018, January 18). Incontinence-associated dermatitis: Management update. American Nurse.
- Glass, D., Huang, D. T., Dugum, M., Chintamaneni, P., Cua, S., Saul, M., Marsh, W., & Al-Khafaji, A. (2018). Rectal Trumpet–Associated Hemorrhage in the Intensive Care Unit. Journal of Wound, Ostomy, and Continence Nursing, 45(6).
- Mount Sinai. (2022). External incontinence devices Information. Mount Sinai.
- National Association for Continence. (2022). How To Prevent And Treat Adult Diaper Rash. National Association For Continence.
- Peden-McAlpine, C., Northwood, M., & Bliss, D. Z. (2018). Fecal Incontinence: Definition and Impact on Quality of Life. Management of Fecal Incontinence for the Advanced Practice Nurse.
- Roland, C. (2022). Fecal Incontinence – StatPearls. NCBI.
- Setya, A., Mathew, G., & Cagir, B. (2022). Fecal Impaction – StatPearls. NCBI.
- Singh, H., Bhaumik, U., Basaveshwara, A., & Singh, A. (2019). Bowel incontinence associated with risperidone: A case report. Telangana Journal of Psychiatry, 5(1).
- Staller, K., Song, M., Grodstein, F., Matthews, C. A., Whitehead, W. E., Kuo, B., Chan, A. T., & Townsend, M. K. (2018). Physical Activity, BMI, and Risk of Fecal Incontinence in the Nurses’ Health Study. Clinical and Translational Gastroenterology, 9(10).
- Yates, A. (2017). Incontinence and associated complications: Is it avoidable? Nurse Prescribing, 15(6).