Transcript Chapter 34

Chapter 23
Incontinence
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Learning Objectives
• Identify the types of urinary and fecal incontinence.
• Explain the pathophysiology and treatment of specific
types of incontinence.
• Identify common therapeutic measures used for the
patient with incontinence.
• List nursing assessment data needed to assist in the
evaluation and treatment of incontinence.
• Assist in developing a nursing care plan for the patient
with incontinence.
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Incontinence
• Definition
• Involuntary passage of urine (urinary incontinence)
or feces (fecal incontinence)
• Many conditions and situations can cause either
temporary or permanent incontinence
• Person with incontinence: physical, psychosocial,
financial burdens
• The management of incontinence in patient care
settings requires many hours of nursing care
• Treatment goals: restore or improve treatable
incontinence, manage irreversible incontinence, and
prevent complications
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Urinary Incontinence:
Prevalence and Costs
• Surveys found that 5%-25% note leakage at least once
a week and 5%-15% experience it daily or most of the
time
• Among U.S. women who live in the community, 15%50% have urinary incontinence; 7%-10% have severe
leakage
• Although twice as common in women compared with
men, 17% of men older than age 60 also have this
condition
• Among men who have had a radical prostatectomy, as
many as 30% have some degree of incontinence
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Urinary Incontinence:
Prevalence and Costs
• The cost of managing the incontinence in the United
States is estimated to be more than $15 billion each
year
• Health care providers need to recognize the economic
and personal value of treating incontinence
aggressively
• Nurses play an important role in educating people
about the need for evaluation and treatment
• Urinary incontinence should not be considered a
normal age-related change
• Often can be improved or cured
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Physiology of Urination
• Urination or micturition
• The passage of urine
• Nurses and physicians commonly refer to the
process of urinating as voiding
• Normal voiding requires healthy bladder
muscles, a patent urethra, normal transmission
of nerve impulses, and mental alertness
• Alterations in any of these factors may result in
incontinence
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Physiology of Urination
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Bladder receives urine continuously from the kidneys
Bladder function: store urine until it can be eliminated
Bladder walls are muscular and capable of stretching
When 200-250 mL of urine collects in the bladder, stretch and
tension receptors are stimulated
The bladder contracts, and the internal sphincter relaxes
Message sent to the brain, making person aware of the need to
void
Because voiding is normally voluntary, it can be delayed
Then the external sphincter can be relaxed, permitting urine to
flow out through the urethra
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Figure 23-1
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Diagnostic Tests and Procedures
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Laboratory Tests
• Clean-catch urinalysis with culture and
sensitivity testing usually ordered to assess for
infection
• The specimen is studied for bacteria, red blood cells,
white blood cells, and glucose; catheterization may
be necessary
• A blood sample collected to measure blood
urea nitrogen, creatinine, glucose, and calcium
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Postvoid Residual
• Amount of urine remaining in the bladder after
voiding
• One method: catheterize patient immediately
after voiding; measure amount of urine
obtained
• A second method is to use an ultrasound
device to estimate the amount of urine
remaining in the bladder after voiding
• Normally less than 50 mL of urine remains
• More than 199 mL reflects inadequate
emptying
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Diagnostic Tests and Procedures
• Imaging procedures
• Computed tomography
• Magnetic resonance imaging
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Urodynamic Testing
• Assess the neuromuscular function of the
lower urinary tract
• These tests indicated when cause of
incontinence cannot be determined by simpler
means
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Uroflowmetry
• Measures voiding duration and the amount and
rate of urine voided
• The patient voids into the funnel of the
flowmeter
• Patient’s position for each voiding is recorded
• Fluid intake measured during testing period
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Cystometry
• Evaluates neuromuscular function of the
bladder
• The patient voids into a flowmeter, after which
a catheter is inserted and the postvoid residual
is measured
• Fluid, air, or both instilled into bladder; patient’s
sensations and bladder response determined
• Bladder is filled until patient feels
uncomfortable or it is apparent that the patient
is unable to sense the pressure
• Bladder drained, or patient is permitted to void
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Provocative Stress Testing
• Detects involuntary passage of urine when
abdominal pressure increases
• Patient may be in a standing or lithotomy
position
• The physician encourages the patient to relax
and then to cough vigorously
• Examiner observes for urine loss during
coughing
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Cystoscopy
• A scope is inserted through urethra to visualize
urethra and bladder
• Procedure may be done under local or general
anesthesia
• Postprocedure care includes monitoring urine
output and encouraging fluid ingestion
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Common Therapeutic Measures
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Bladder Training
• Patient education
• Information about normal urinary anatomy and
physiology and the bladder retraining program
• Scheduled toileting
• The patient is encouraged to delay voiding and void
only at scheduled times
• Positive reinforcement
• The patient’s efforts and improvement are positively
reinforced throughout the treatment period, which
usually lasts several months
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Habit Training
• Similar to bladder training in that patient is
encouraged to void at scheduled intervals
• The difference is that the patient is not advised
to resist the urge and delay voiding
• The voiding schedule is based on the patient’s
usual pattern
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Prompted Voiding
• Often used with habit training for people who
are dependent or cognitively impaired
• Caregiver checks the patient for wetness at
regular intervals and asks the patient to state
whether wet or dry
• Caregiver encourages the patient to try to use
the toilet
• Caregiver praises patient for trying to use the
toilet and for remaining dry
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Pelvic Muscle Rehabilitation
• Aims to strengthen the pelvic floor
• Kegel exercises
• Actively exercise the pubococcygeus muscle
• Biofeedback
• Electronic or mechanical sensors are used to help the
patient isolate the appropriate pelvic muscles to contract
while keeping the abdominal muscles relaxed
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Pelvic Muscle Rehabilitation
• Vaginal weights
• Ceramic devices of various weights are inserted into
the vagina
• Begins with lightest cone, inserts it, and tries to
retain it for up to 15 minutes twice daily
• When lightest cone successfully retained, heavier
cones then used in succession
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Urge Suppression
• If you have the urge to void, stop what you are doing;
sit down or stand quietly
• Quickly squeeze the pelvic floor muscles several times
without resting between squeezes
• Take a few deep breaths and try to relax except for the
pelvic floor muscles
• Try to suppress the urge to void
• Wait until the urge passes
• While continuing to squeeze the pelvic floor muscles,
walk to the bathroom at a normal pace
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Reflex Training
• Uses the Valsalva maneuver with rectal
stretching to force urine from the bladder
• Valsalva maneuver performed by taking a deep
breath, holding it, and bearing down
• At the same time, the rectum is stretched by
inserting a gloved finger into the rectum and
pulling toward the back
• This creates pressure on the urinary sphincter and
relaxes the pelvic floor, allowing urine to flow
• Patients who use this method should be
checked for residual volume at times
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Drug Therapy
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Anticholinergics
Smooth muscle relaxants
Calcium channel blockers
Tricyclic antidepressant agents
Nonsteroidal anti-inflammatory drugs
Alpha-adrenergic agonists
Estrogen
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Drug Therapy
• Creams and sprays are available to coat and
protect the skin of the perineum and buttocks
of the incontinent patient
• A light dusting powder can be used to absorb
moisture
• Cornstarch not recommended: promotes yeast
infection development
• Do not use talc and lotion together on the
same area because the combination creates
an abrasive paste
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Urine Collection Devices: External
• Useful for males
• Latex sheaths, sometimes called condom catheters or
Texas catheters, drain urine into a bag that is usually
secured to the leg
• Effective in maintaining dryness, but the adhesive may
cause skin irritation on the penis
• Make sure the patient and all caregivers know not to
encircle the penis with tape
• To do so can restrict circulation
• Use elastic tape; wrap in a spiral pattern
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Urine Collection Devices
• Indwelling catheters
• To control urinary incontinence
• Usually done when all other measures have failed
and skin integrity is endangered
• A catheter may also be needed temporarily if urine
is coming in contact with a wound
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Urine Collection Devices
• Intermittent self-catheterization
• Requires dexterity, adequate vision, and ability and
motivation to learn
• Clean technique rather than sterile is usually taught
for use in the home setting
• Initially the bladder is drained every 4 hours;
adjusted according to amount of residual
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Urine Collection Devices
• Garments and pads for incontinence
• Help maintain dryness
• Disposable briefs and pads
• “Geri pads”
• Washable waterproof briefs; absorbent cotton liners
• Another style: stretchy brief with a perineal pouch through
which absorbent pads can be changed
• The best product is one that draws urine away from
the skin through a liner that remains dry
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Garments and Pads for Incontinence
• Penile clamp
• A device applied to the penis
• It compresses the urethra, preventing the passage
of urine
• To prevent circulatory impairment and pressure
sores, the clamp must be removed and repositioned
frequently
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Figure 23-2
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Pelvic Organ Support Devices
• Pessary
• Device inserted into the vagina to hold the pelvic
organs in place
• Sometimes used to treat incontinence in women
with relaxation of pelvic structures
• A doughnut-shaped pessary exerts pressure on the
vaginal wall, lifting the uterus and holding it in the
pelvis
• Must be removed periodically for cleansing and
replacement as needed
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Pelvic Organ Support Devices
• Bladder neck support prosthesis
• For women with stress incontinence
• The Silastic device is fitted into the vagina
• It supports the area where the urethra connects to the
bladder, thereby reducing the incidence of involuntary urine
loss
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Surgical Treatment
• Surgical procedures
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Remove obstructions
Treat severe detrusor overactivity
Implant an artificial sphincter
Reposition the sphincter unit
Improve perineal support
Inject substances that increase urethral
compression
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Surgical Treatment
• Implantation of electrodes
• Electrostimulation: electrodes that stimulate the
pelvic floor muscles
• Retropubic urethropexies and pubovaginal
slings
• Surgical procedures most often used for stress
urinary incontinence in women
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Surgical Treatment
• Artificial sphincter
• Inflatable cuff, a reservoir of fluid that fills the cuff,
and a pump
• Cuff is positioned around the urethra or bladder
neck
• Reservoir is placed in the abdomen and the pump in
the scrotum or labia
• Fluid fills the cuff, applying pressure to the urethra
to prevent urine passage
• To void, patient compresses the pump, which
deflates the cuff by transferring fluid from cuff to the
reservoir and allowing urine to pass through the
urethra
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Figure 23-3
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Types of Urinary Incontinence
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Urge Incontinence
• The involuntary loss of urine shortly after a
strong, abrupt urge to urinate
• Idiopathic urge incontinence
• A specific cause cannot be identified
• Neurogenic detrusor overactivity
• Associated with neurologic disorders, such as
stroke, multiple sclerosis, and spinal cord lesions
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Urge Incontinence
• Management
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Aimed at correcting the cause, if possible
Behavioral techniques
Drug therapy
Surgical intervention
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Overflow Incontinence
• Involuntary urine loss from overdistended bladder
• Small amounts of urine are lost continuously or at
frequent intervals
• Contributing factors
• Obstruction to urine flow, an underactive detrusor muscle, or
impaired transmission of nerve impulses
• Patients not aware of bladder fullness, and the bladder may
become overdistended
• Neurogenic bladder: retention with overflow caused by
neurologic dysfunction associated with spinal cord injury,
radical pelvic surgery, or radiation cystitis
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Overflow Incontinence
• Management
• Depends on the cause
• The physician may prescribe drugs to stimulate the
bladder and relax the internal sphincter
• Surgical removal of all or part of the prostate
• Sphincterotomy
• Intermittent or indwelling catheterization
• Credé’s method
• Valsalva maneuver
• Anal stretch maneuver
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Stress Incontinence
• The involuntary loss of small amounts of urine during
physical activity that increases abdominal pressure
• Coughing, laughing, sneezing, and lifting
• In women, caused by relaxation of the pelvic floor
muscles and the urethrovesical juncture as a result of
pregnancy, childbirth, obesity, and aging
• Urethral trauma, sphincter injury, congenital sphincter
weakness, urinary infection, stress, and neurologic
disorders cause stress incontinence in men and
women
• It may occur after prostatectomy or radiation therapy
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Stress Incontinence
• Management
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Behavioral methods
Maintain a fluid intake of at least 2000 mL/day
Avoid fluids with diuretic effect (tea, coffee, cola)
Alpha-adrenergic drugs: pseudoephedrine HCl
(Sudafed)
• Oral or topical estrogen
• Retropubic urethropexies, pubovaginal slings, and
collagen injections
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Functional Incontinence
• Description
• Voiding inappropriately because unable to get to the
toilet or to manage the mechanics of toileting
• Related to confusion, immobility, or barriers in the
environment
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Functional Incontinence
• Management
• Depends on the cause
• Environment should be arranged to permit
independent toileting
• Assistive devices enable immobile patient to void
appropriately
• The confused patient may respond well to
scheduled or timed voiding and efforts to improve
orientation to toilet facilities
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Nursing Care of the Patient with
Urinary Incontinence
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Health History
• Chief complaint
• Thorough description of chief complaint is essential
• Ask whether the patient is aware of the need to void
and able to hold the urine once the need is felt
• Determine the pattern of incontinent voiding, urine
volume, and related symptoms
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Health History
• Past medical history
• Urologic, gynecologic, neurologic, and endocrine
conditions
• Specifically ask if patient has diabetes mellitus
• Document all abdominal disorders, surgeries, and
trauma
• Record the number of pregnancies and types of
deliveries
• Inquire about current and recent medications
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Health History
• Review of systems
• The review of systems may detect clues to
conditions that contribute to incontinence
• Constipation can contribute to incontinence
• Functional assessment
• Patient’s usual activities and habits provide clues
about possible contributing factors, and about the
impact of incontinence on the individual
• Of special interest in relation to incontinence are
usual fluid intake and consumption of alcohol
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Physical Examination
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Measurement of vital signs and height and weight
Be alert for fever, tachycardia, and weight gain
Level of awareness and appropriateness of responses
Inspect the skin for edema
Palpate the abdomen for masses, tenderness, fullness,
or distention
• Inspect the female perineum for redness or irritation
• Assess the environment, including toilet accessibility,
grab bars, lighting, and availability of toileting options
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Deficient Knowledge
• Patient and caregiver education key to
managing urinary incontinence
• Emphasize that improvement or correction is
possible for most people
• The teaching plan includes an overview of
normal urination, an explanation of the type of
incontinence, and detailed explanations of the
prescribed treatment
• Praise patient for working toward continence,
participating in treatment plan, and voiding
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Bladder Training or Retraining
• Recommended for stress and urge incontinence
• Establish schedule for voiding every 2 to 3 hours
• Patient is not usually asked to get up during the night,
so pads or an external collection device may be
needed during sleep
• Emphasize the importance of the patient trying to delay
voiding until the scheduled time
• Praise patient’s efforts and encourage the caregiver to
do so as well
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Habit Training
• Incontinence record: establish timed voiding
• You or other caregivers must then remind the
patient to try to void at the scheduled times
• If the patient has difficulty voiding at the scheduled
time, try to stimulate voiding
• To promote voiding, establish a comfortable position
for patient, ensure privacy, and use specific stimuli
• Fluid intake may be spaced at 2-hour intervals to
provide regular filling of the bladder. Nighttime
wetness can be reduced by limiting fluids after 7 pm
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Figure 23-4
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Social Isolation
• The person with urinary incontinence may
curtail social activities out of fear of having
embarrassing accidents
• Access to public toilets often limited, so
patients who cannot delay voiding may be
afraid to venture far from home
• Incontinence products may permit patient to
venture out without fear of wetness or odor
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Situational Low Self-Esteem
• Incontinent adults: too embarrassed to tell
anyone about it
• Encourage patient to attend to dress and
grooming to promote positive self-image
• The patient who takes an active role in carrying
out the treatment plan may feel less helpless
and better able to cope with incontinence
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Impaired Skin Integrity
• Skin breakdown: major problem for incontinent
patient
• Urine and feces, if left in contact with the skin,
cause a rash
• Continuous moisture causes the skin to lose its oily
protective barrier
• The key to preventing breakdown is to keep the skin
clean, dry, and free of urine or feces
• Inspect the genitals, perineum, thighs, and buttocks
for redness and skin breakdown
• Apply protective creams according to agency policy
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Risk for Infection
• Patient incontinent of urine is at risk for urinary tract
infection and urinary calculi
• Retained urine medium for bacterial growth, and the
overstretched bladder wall is susceptible to infection
• Patients may restrict fluid intake to reduce incontinence
• Concentrated urine risk factor for infections and calculi
• Reduce risk of urinary tract infection: have patient
empty the bladder as scheduled, provide adequate
fluids, and use strict aseptic technique during
catheterization
• Keep the perineal area clean
• Intake of 2000-3000 mL fluid daily unless
contraindicated
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Fecal Incontinence
• Fecal incontinence is less common than urinary
incontinence, but it can be very distressing for patients
• Usually related to anal sphincter dysfunction caused by
anal surgery, trauma during childbirth, Crohn’s disease
affecting the anus, or diabetic neuropathy
• Some experience temporary incontinence with severe
diarrhea because they do not have time to reach the
toilet
• Incontinent diarrhea may also be present with fecal
impaction
• Diminished muscle strength with aging also a factor
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Physiology of Defecation
• The muscles of the pelvic floor and the external
sphincter are under voluntary control
• The bowel has its own nerve network that stimulates
peristalsis when it is distended
• Disorders of the central nervous system and spinal cord do not
impair bowel control as much as they do bladder control
• The fecal mass enters the rectum by mass movement
• Feces in the rectum creates a desire to defecate
• Defecation occurs when the anal sphincter relaxes and
the rectum contracts
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Figure 23-5
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Diagnostic Tests and Procedures
• Evaluation of fecal incontinence may include
• Assessment of rectal sphincter tone
• Laboratory examination of a stool specimen for
blood or pathogens
• Endoscopic or radiologic procedures to detect
underlying problems
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Common Therapeutic Measures
• Enemas
• Stimulate emptying of the bowel in patient prone to
impaction
• Pouches
• May be applied to the perianal area and held in
place with adhesive
• Helpful for patients who have frequent stools
• Drug therapy
• Laxatives, stool softeners, and antidiarrheal drugs,
depending on the cause of the incontinence
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Common Therapeutic Measures
• Biofeedback
• Motivated patients able to follow directions and
whose external anal sphincter is capable of
responding to rectal distention may achieve bowel
control
• Dietary changes
• Raw fruits, fruit juices (especially prune and grape
juice), raw vegetables, cabbage, sweets, alcohol,
and highly spicy foods stimulate stool production
• Foods that thicken the stool include bananas, rice,
bread, potatoes, cheese, yogurt, oatmeal, oat bran,
boiled milk, and pasta
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Types of Fecal Incontinence
• Fecal overflow incontinence
• Caused by constipation in which the rectum is
constantly distended
• Medical treatment
• Immediate relief of the constipation and long-term
control of the problem
• Cleanse the colon
• Regular evacuation
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Types of Fecal Incontinence
• Neurogenic incontinence
• Defecation is not voluntarily delayed
• One or two formed stools occur after meals
• Medical treatment
• Scheduled toileting based on usual time of
defecation
• If not successful, physician orders a constipating
drug (such as codeine) each morning and a laxative
(senna or milk of magnesia) each night
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Types of Fecal Incontinence
• Symptomatic incontinence
• Result of colorectal disease
• Medical treatment
• Identify and treat the cause
• Anorectal incontinence
• Nerve damage that causes the muscles of the pelvic
floor to be weak
• Medical treatment
• Pelvic muscle exercises; sometimes biofeedback
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Nursing Care of the Patient with
Fecal Incontinence
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Health History
• Chief complaint
• Determine usual bowel pattern, changes, stool
characteristics, and related symptoms, such as pain
or cramping
• Bowel pattern
• Document usual frequency of bowel movements
• Characteristics of stools
• Assess consistency, color, and constituents of stools
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Health History
• Past medical history
• Document chronic illnesses, past acute illnesses,
and surgeries or trauma to the abdomen or rectum
• Neurologic conditions, including stroke, spinal cord
injury, and dementia, are significant
• List recent and current medications and all allergies
• Especially important to determine the use of
laxatives, enemas, or suppositories
• Record obstetric history, including the number of
pregnancies, types of deliveries, and complications
of childbirth
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Health History
• Review of systems
• Problems that may be related to fecal incontinence,
such as motor, sensory, or cognitive impairments
• Functional assessment
• Habits that may be related to bowel function,
including diet, fluid intake, exercise or activity
pattern
• Physical examination
• Inspect and palpate the abdomen for distention and
auscultate for bowel sounds
• Inspect the perianal area for irritation or breakdown
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Bowel Incontinence
• Continued monitoring
• Documentation of usual bowel pattern
• Explain normal bowel physiology and
interventions for incontinence to the patient
• Advise the patient to consume adequate fluids
and fiber to prevent constipation and impaction
• A fluid intake of 2000 mL/day
• Fresh fruits and vegetables provide bulk/fiber
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Impaired Skin Integrity
• After each incontinent stool, cleanse the
patient’s perianal area thoroughly
• Apply creams or ointments per agency policy
• Incontinence undergarments may be needed to
prevent soiling and embarrassment but must be
checked frequently so that stool does not remain in
contact with the skin
• Fecal pouches may be used, but the adhesive and
plastic can irritate the skin, so good skin care is still
a priority
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Situational Low Self-Esteem
• Loss of bowel control can be devastating
• Express understanding of the patient’s distress
and encourage to strive for as much
improvement as possible
• Praise for participation in the treatment
program and decreased frequency of
incontinent stools
• Encourage to practice good grooming and
resume social activities
• Help coordinate patients’ social schedule with
their bowel programs
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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