Fecal Incontinence Management

Fecal incontinence, the involuntary passage of feces, may occur gradually (as in dementia) or suddenly (as in spinal cord injury). It usually results from fecal stasis and impaction secondary to reduced activity, inappropriate diet, or untreated painful anal conditions. It can also result from chronic laxative use; reduced fluid intake; neurologic deficit; pelvic, prostatic, or rectal surgery; and the use of certain medications, including antihistamines, psychotropics, and iron preparations. Not usually a sign of serious illness, fecal incontinence can seriously impair an elderly patient's physical and psychological well-being.

Patients with urinary or fecal incontinence should be carefully assessed for underlying disorders. Most can be treated; some can even be cured. Treatment aims to control the condition through bladder or bowel retraining or other behavior management techniques, diet modification, drug therapy, pessaries, and, possibly, surgery. Corrective surgery for urinary incontinence includes transurethral resection of the prostate in men, urethral collagen injections for men or women, repair of the anterior vaginal wall or retropelvic suspension of the bladder in women, urethral sling, and bladder augmentation.

Equipment

Bladder retraining record sheet • gloves • stethoscope (to assess bowel sounds) • lubricant • moisture barrier cream • antidiarrheal or laxative suppository • incontinence pads • bedpan • specimen container • label • laboratory request form • optional: stool collection kit, urinary catheter.

Implementation

Whether the patient reports urinary or fecal incontinence or both, you'll need to perform initial and continuing assessments to plan effective interventions.

For fecal incontinence

• Ask the patient with fecal incontinence to identify its onset, duration, severity, and pattern (for instance, determine whether it occurs at night or with diarrhea). Focus the history on GI, neurologic, and psychological disorders.
• Note the frequency, consistency, and volume of stools passed in the past 24 hours. Obtain a stool specimen if ordered. Protect the patient's bed with an incontinence pad.
• Assess for chronic constipation, GI and neurologic disorders, and laxative abuse. Inspect the abdomen for distention, and auscultate for bowel sounds. If not contraindicated,
  check for fecal impaction (a factor in overflow incontinence).
• Assess the patient's medication regimen. Check for drugs that affect bowel activity, such as aspirin, some anticholinergic antiparkinsonian agents, aluminum hydroxide, calcium carbonate antacids, diuretics, iron preparations, opiates, tranquilizers, tricyclic antidepressants, and phenothiazines.
• For the neurologically capable patient with chronic incontinence, provide bowel retraining.
• Advise the patient to consume a fiber-rich diet that includes lots of raw, leafy vegetables (such as carrots and lettuce), unpeeled fruits (such as apples), and whole grains (such as wheat or rye breads and cereals). If the patient has a lactase deficiency, suggest that he take calcium supplements to replace calcium lost by eliminating dairy products from the diet.
• Encourage adequate fluid intake.
• Teach the elderly patient to gradually eliminate laxative use. Point out that using laxatives to promote regular bowel movement may have the opposite effect, producing either constipation or incontinence over time. Suggest natural laxatives, such as prunes and prune juice, instead.
• Promote regular exercise by explaining how it helps to regulate bowel motility. Even a nonambulatory patient can perform some exercises while sitting or lying in bed.

Special considerations

• For fecal incontinence, maintain effective hygienic care to increase the patient's comfort and prevent skin breakdown and infection. Clean the perineal area frequently, and apply a moisture barrier cream. Control foul odors as well.
• Schedule extra time to provide encouragement and support for the patient, who may feel shame, embarrassment, and powerlessness from loss of control.

Complications

Skin breakdown and infection may result from incontinence. Psychological problems resulting from incontinence include social isolation, loss of independence, lowered self-esteem, and depression.

Documentation

Record all bladder and bowel retraining efforts, noting scheduled bathroom times, food and fluid intake, and elimination amounts, as appropriate. Document the duration of continent periods. Note any complications, including emotional problems and signs of skin breakdown and infection as well as the treatments given for them.

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Educational and Competency Requirements for The Administration and Supply of Medications by Nurses in Rural and Remote Areas

Following are the areas of responsibility that rural and remote nurses must accept if medication management is to become part of their legal practice.

Knowledge of Medicines:
Nurses should have contemporary knowledge of pharmacology for safe and appropriate nursing practice in rural and remote communities. The nurse also must have sound knowledge and skills relating to medications in their facility’s approved medication list. Another requirement is that the nurse should have reasonable access to and familiarity with the resources available for collaboration, consultation/reference in regards to the use of medications.
Relevant and appropriate clinical educational preparation and competency assessment will support best practice in the administration and supply of medication by registered nurses in rural and remote settings.

Knowledge of Law:
The nurse must have knowledge of the statutory and common laws, which govern medication use by registered nurses, for practice.

Civil laws, statutory acts and regulations establish the standard of the delivery of appropriate and safe care to patients. Knowledge of the legislative requirements is essential to ensure registered nurses’ practise within the law.

Assessment of Competency:
The practice of initiating, administering and supplying medications in rural or remote areas should be confined to registered nurses who have demonstrated competency in these areas.
An assessment of competency should include:

• Knowledge and skills for patient assessment and diagnosis
• An examination of medication knowledge.
• A test of competency in medication calculations.
• Knowledge of the medication schedules as they impact on clinical practice.
• A clinical/practical assessment of compliance with protocols in the practice context.

Knowledge of clinical assessment and medication use is essential to enable the nurse to make an informed decision about the initiation of safe and appropriate treatment. Competency in medication/IV calculations may reduce the risk of dose/rate errors. It is the nurse’s responsibility to have knowledge of current schedules to practise in accordance with the relevant legislation. Current literature indicates that a significant number of nursing students have serious numeracy skill deficits and that even if these skills are mastered, they can deteriorate if not continually exercised.

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What Are Involve at Planning of Care?

Planning involves three subsets: setting priorities, writing expected outcomes, and establishing target dates. Planning sets the stage for writing nursing actions by establishing where we are going with our plan of care. Planning further assists in the final phase of evaluation by defining the standard against which we will measure progress.

Setting Priorities
With the sicker, quicker problem discussed earlier, you are going to find yourself in the situation of having identified many more problems than can possibly be resolved in a 1- to 3-day hospitalization (today’s average length of stay). In the long-term care facilities, such as home health, rehabilitation, and nursing homes, long-range problem solving is possible, but setting priorities of care is still necessary.

Several methods of assigning priorities are available. Some nurses assign priorities based on the life threat posed by a problem. For example, Ineffective Airway Clearance would pose more of a threat to life than the diagnosis Risk for Impaired Skin Integrity. Some nurses base their prioritization on Maslow’s Hierarchy of Needs. In this instance, physiologic needs would require attention before social needs. One way to establish priorities is to simply ask the patient which problem he or she would like to pay attention to first. Another way to establish priorities is to analyze the relationships between problems. For example, a patient has been admitted with a medical diagnosis of headaches and possible brain tumor. The patient exhibits the defining characteristics of both Pain and Anxiety. In this instance, we might want to implement nursing actions to reduce anxiety, knowing that if the anxiety is not reduced, pain control actions will not be successful. Once priorities have been established, you are ready to establish expected outcomes.

Expected Outcomes
Outcomes, goals, and objectives are terms that are frequently used interchangeably because all indicate the end point we will use to measure the effectiveness of our plan of care.

Several guidelines for writing clinically useful expected outcomes:

1. Expected outcomes are clearly stated in terms of patient behavior or observable assessment factors.
2. Expected outcomes are realistic, achievable, safe, and acceptable from the patient’s viewpoint.
3. Expected outcomes are written in specific, concrete terms depicting patient action.
4. Expected outcomes are directly observable by use of at least one of the five senses.
5. Expected outcomes are patient centered rather than nurse centered.

Establishing Target Dates
Writing a target date at the end of the expected outcome statement facilitates the plan of care in several ways:

1. Assists in “pacing” the care plan. Pacing helps keep the focus on the patient’s progress.
2. Serves to motivate both patients and nurses toward accomplishing the expected outcome.
3. Helps patient and nurse see accomplishments.
4. Alerts nurse when to evaluate care plan.

Target dates can be realistically established by paying attention to the usual progress and prognosis connected with the patient’s medical and nursing diagnoses. Additional review of the data collected during the initial assessment helps indicate individual factors to be considered in establishing the date. For example, one of the previous expected outcomes was stated as “Accurately return-demonstrates self-administration of insulin by 9/11.”

The progress or prognosis according to the patient’s medical and nursing diagnosis will not be highly significant. The primary factor will be whether diabetes mellitus is a new diagnosis for the patient or is a recurring problem for a patient who has had diabetes mellitus for several years.

For the newly diagnosed patient, we would probably want our deadline day to be 5 to 7 days from the date of learning the diagnosis. For the recurring problem, we might establish the target date to be 2 to 3 days from the date of diagnosis. The difference is, of course, the patient’s knowledge base.

Now look at an example related to the progress issue. Mr. X is a 19-year-old college student who was admitted early this morning with a medical diagnosis of acute appendicitis. He has just returned from surgery following an appendectomy. One of the nursing diagnoses for Mr. X would, in all probability, be Pain. The expected outcome could be “Will have decrease in number of requests for analgesics by [date].” In reviewing the general progress of a young patient with this medical and nursing diagnosis, we know that generally analgesic requirements start decreasing within 48 to 72 hours. Therefore, we would want to establish our target date as 2 to 3 days following the day of surgery. This would result in the objective reading (assume date of surgery was 11/1): “Will have decrease in number of requests for analgesics by 11/3.”

To further emphasize the target date, it is suggested that the date be underlined, highlighted by using a different-colored pen, or circled to make it stand out. Pinpointing the date in such a manner emphasizes that evaluation of progress toward achievement of the expected outcome should be made on that date. In assigning the dates, be sure not to schedule all the diagnoses and expected outcomes for evaluation on the same date. Such scheduling would require a total revision of the plan of care, which could contribute to not keeping the plan of care current. Being able to revise single portions of the plan of care facilitates use and updating of the plan. Remember that the target date does not mean the expected outcome must be totally achieved by that time; instead, the target date signifies the evaluation date.

Once expected outcomes have been written, you are then ready to focus on the next phase—implementation. As previously indicated, the title supported by this book for this section is “Nursing Actions.”

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Focus Charting System As Nursing Documentation Tool

The Focus Charting system has been designed by nurses for documentation of frequent/repetitive care and to encourage viewing the client from a positive rather than a negative (problem only) perspective. Charting is focused on client and nursing concerns, with the focal point of client status and the associated nursing care. A Focus is usually a client problem/concern or nursing diagnosis but is not a medical diagnosis or a nursing task/treatment (e.g., wound care, indwelling catheter insertion, tube feeding).

We track what is happening to the client at any given moment by recording of assessment, interventions, and evaluation using Data, Action, and Response (DAR) categories. Thus, the four components of this charting system are:

1. Focus: Nursing diagnosis, client problem/concern, signs/ symptoms of potential importance (e.g., fever, dysrhythmia, edema), a significant event or change in status or specific standards of care/agency policy.
2. Data: Subjective/objective information describing and/or supporting the Focus.
3. Action: Immediate/future nursing actions based on assessment and consistent with/complementary to the goals and nursing action recorded in the client plan of care.
4. Response: Describes the effects of interventions and whether the goal was met.

You can find charting examples that based on the data within the client situation by using google search.

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