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Fecal incontinence management

NURSING CARE/PATIENT DIGNITY

Fecal incontinence is a problem in the critical-care setting and presents a number of challenges for the nurse, patient, and patient’s family.¹

Nursing care

Caring for patients with fecal incontinence can be:

• Labor-intensive¹
• Time-consuming¹
• A concern in that it can lead to skin breakdown and resulting infection¹

Potential effects of fecal incontinence can range from superficial skin irritation to perineal dermatitis and serious infection.¹

Patient dignity

Fecal incontinence can be uncomfortable and embarrassing for the patient and also his or her family.¹

It is important that fecal incontinence is dealt with efficiently and in a manner that addresses the patient’s needs for comfort and dignity.

SKIN BREAKDOWN AND INFECTION

When skin is exposed to feces, there is a risk of skin breakdown and infection.⁴

Overexposure to moisture can cause the skin to become macerated (waterlogged), which, in turn, makes the skin very fragile. This added fragility increases the risk for damage caused by friction, shear, and pressure. Once skin is macerated, even gentle rubbing by bed linens, diapers, and washcloths can cause injury.⁴

Macerated skin is also at risk of bacterial infection.⁴

Clostridium difficile – an important issue in fecal incontinence care

C. difficile is carried in the digestive system in fewer than 3% of the healthy adult population.⁵ It can cause infection in patients who are treated with antibiotics and can be spread to other vulnerable patients. Specific toxin-producing strains of C. difficile have caused significant outbreaks of infection in hospitals resulting in patient deaths.⁶ Large numbers of spores are excreted in the diarrhea of an infected patient. These spores are highly resistant and easily spread to contaminate the environment. Hospital-acquired infection occurs via person-to-person contact or contaminated environments. C. difficile can cause mild-to-severe diarrhea and although the majority of patients can expect a full recovery, C. difficile can potentially result in ulceration and perforation of the intestine (pseudomembranous colitis) and can be fatal.⁷ In some countries, C. difficile is becoming a greater threat to patients than MRSA (methicillin resistant staphylococcus aureus).⁶

SKIN CARE AND INFECTION CONTROL

In the management of incontinence, the three most important steps for skin care protection are:

• Step 1 — Cleansing
• Step 2 — Conditioning
• Step 3 — Keeping the skin dry

The Agency for Healthcare Research and Quality guidelines recommend the following interventions for care of incontinent patients (AHCPR Publication No. 92-0047)

• Cleanse the skin at the time of soiling and at routine intervals
• Individualize the frequency of skin cleansing according to need and/or patient preference
• Avoid hot water
• Use a mild cleansing agent that minimizes irritation and dryness of the skin
• Cleanse gently – be careful to minimize the force and friction applied to the skin

To prevent skin breakdown due to incontinence

• Prevent excessive skin wetness
• Maintain the skin at its natural pH range (between four and seven)
• Minimize direct contact with urine and feces

THE COSTS OF FECAL INCONTINENCE

• Nursing time required
• Materials needed to care for patients
• Changing bed linens/laundering

Ineffective fecal diversion and containment may lead to complications that have the potential to be costly, including:

Skin breakdown

• Can increase a patient’s hospital stay by four days²

Infection

• Hospital-acquired infection can increase a patient’s hospital stay by 10 days²
• Additional treatment costs can directly result from a hospital-acquired infection⁸

Effective fecal containment reduces the risk of wound infection.

ConvaTec has a product designed to specifically help the nursing staff minimize wound and environmental contamination and improve patient care.

• The challenge of skin breakdown
• The challenge of infection
• The challenge of patient care
• On-call Specialist Program

References [+]

1. Beitz JM. Fecal Incontinence in Acutely and Critically Ill patients: Options in Management. Ostomy Wound Manage. 2006; 52(12):56-66.
2. Zhan C, Miller MR. Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization. JAMA 2003; 290(14):1864-1874
3. Padmanabhan A et al. Clinical Evaluation of a Flexible Fecal Incontinence Management System. AJCC 2007; 16(4):384-392.
4. Gray M, et al. Perineal Skin Care for the Incontinent Patient. Advances in Skin and Wound Care 2002, 15(4):170-175.
5. Schroeder MS. Clostridium difficile-Associated Diarrhea. American Family Physician. 2005; 71(5):921-928.
6. News and Events. Healthcare watchdog reveals serious failings in hospital’s response to outbreaks of potentially deadly infection. Healthcare commission. http://www.healthcarecommission.org.uk. Accessed November 26, 2007.
7. A Simple Guide to Clostridium difficile. Department of Health. http://www.dh.gov.uk. Accessed November 26, 2007.
8. Stone PW, et al. A systematic audit of economic evidence linking nosocomial infections and infection control interventions: 1990-2000. AJIC 2002; 30(3):145-152.