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Chapter 23 Incontinence Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 1 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. Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 2 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 3 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 4 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 5 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 6 Physiology of Urination • • • • • • • • 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 7 Figure 23-1 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 8 Diagnostic Tests and Procedures Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 9 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 10 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 11 Diagnostic Tests and Procedures • Imaging procedures • Computed tomography • Magnetic resonance imaging Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 12 Urodynamic Testing • Assess the neuromuscular function of the lower urinary tract • These tests indicated when cause of incontinence cannot be determined by simpler means Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 13 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 14 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 15 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 16 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 17 Common Therapeutic Measures Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 18 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 19 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 20 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 21 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 22 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 23 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 24 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 25 Drug Therapy • • • • • • • Anticholinergics Smooth muscle relaxants Calcium channel blockers Tricyclic antidepressant agents Nonsteroidal anti-inflammatory drugs Alpha-adrenergic agonists Estrogen Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 26 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 27 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 28 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 29 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 30 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 31 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 32 Figure 23-2 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 33 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 34 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 35 Surgical Treatment • Surgical procedures • • • • • • Remove obstructions Treat severe detrusor overactivity Implant an artificial sphincter Reposition the sphincter unit Improve perineal support Inject substances that increase urethral compression Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 36 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 37 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 38 Figure 23-3 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 39 Types of Urinary Incontinence Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 40 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 41 Urge Incontinence • Management • • • • Aimed at correcting the cause, if possible Behavioral techniques Drug therapy Surgical intervention Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 42 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 43 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 44 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 45 Stress Incontinence • Management • • • • 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 46 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 47 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 48 Nursing Care of the Patient with Urinary Incontinence Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 49 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 50 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 51 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 52 Physical Examination • • • • • 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 53 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 54 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 55 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 56 Figure 23-4 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 57 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 58 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 59 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 60 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 61 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 62 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 63 Figure 23-5 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 64 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 65 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 66 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 67 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 68 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 69 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 70 Nursing Care of the Patient with Fecal Incontinence Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 71 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 72 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 73 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 74 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 75 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 76 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. 77