Care Plan for Bowel Incontinence?

[am0r803]

Hi all,

Was wondering if I can get some help (which i usually ALWAYS do when I come to this site!)

Im finishing up my care plans for my last patient and the last problem I am working on is his bowel and urinary incontinence. Here's my dilemma - I'm not completely sure why he has bowel and urinary incontinence.

Here's his history

86 year old male sent from nursin home for large amount of blood via rectum. Has a Stage 4 pressure ulcer on sacrum, Has a history of HTN, CHF, Pneumonia, Diabetes, A-fib, Sepsis, Anemia and had a Left AKA in February. Patient has been experiencing diarrhea due to being on Vancomycin IV. Also, some of his lab values have been out of range... Calcium was 5.6, Hgb was 7.2, Hct was 21.4, K+ was 3.1 - was treated for high potassium, dropped to normal range, and now is low.

Ok, so I did diagnoses for his list of other problems, his pressure ulcer, his lab values, his diarrhea etc.. So the last thing I'm doing is the bowel and urinary incontinence and my assumption was that its due to his old age? Does that make sense? I don't know but I'm not sure what to put as the related to in the diagnosis. Also, is it possible to put urinary and bowel incontinence in one diagnosis? Don't think it is but just asking....

Any insight is as always greatly appreciated!

Thanks!

[UM Review RN, ASN, RN]

Frankly, one of the things that will cause bowel incontinence in a previously continent patient who has been getting a lot of antibiotics, is C. Diff.

I don't know if there's a care plan problem listing for frequent liquid stooling causing incontinence, but if ever there was a medical problem that might cause incontinence, C. Diff. would have to be it and your patient has a couple of big risk factors for it.

[Daytonite, BSN, RN]

i worked with care plans and nursing diagnoses all the time and that diarrhea just glared out at me when i read your post. you know, when you get old, as i'm finding out, and they put you on these antibiotics, the old skeletal frame just doesn't get you to the bathroom in the hippity-hop fashion it did when we were kids. those antibiotics do a number on the flora of the colon and the diarrhea derby starts. plus, this man has a sacral ulcer about as bad as it can get (stage iv!!!) so i'm guessing he was bedridden or wheelchair bound anyway. i wouldn't even go near a bowel incontinence diagnosis because the diarrhea solves your problem with the etiology. go simple. you are identifying and solving problems with a care plan. i'd save bowel incontinence for another day and work with the diarrhea first. i'd use diarrhea r/t adverse effect of antibiotic aeb [number of diarrhea stools per day + any other symptoms]. you can address and include incontinence issues in the interventions under this diagnosis since urgency is one of the defining characteristics (maybe he just can't use the call bell or a bedpan--was this assessed?). look at the nanda taxonomy information on the related factors and defining characteristics for this diagnosis. here are links to webpages if you don't have a care plan book with this information: [color=#3366ff]diarrhea and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=16

by the by, make sure you use impaired tissue integrity for a stage iv ulcer and not impaired skin integrity.

[am0r803]

Thanks so much for that information...

Actually, my patient doesn't even tell you when he has gone to the bathroom. I would ask him, and he'd tell me no, and then when I would go to move him or change him, he'd be soiled. But, there's no history of dementia or anything like that but I would definitely say there's something wrong with his cognitive function?? He's able to tell you if he's in pain but thats about it.

Now, two more things if you don't mind - the Impaired Tissue Integrity as opposed to the Impaired Skin Integrity... is that because the Pressure ulcer is a Stage 4?? And also, my patient is on Lactobacillus/Acidophilus and I can't find this in my medication book. From what I remember - this is for infection also no? I've only had like one other patient on it and I can't remember the details about it. If you could give me some help, thanks!

Oh, and no my patient doesn't have C-diff!

[Daytonite, BSN, RN]

A stage IV ulcer has invaded the subcutaneous skin or structures below it. The definition of Impaired Skin Integrity is altered dermis or epidermis, as opposed to Impaired Tissue Integrity which is damage to mucous membrane, corneal, integumentary, or subcutaneous tissues. I worked with these diagnoses in nursing homes all the time and the difference while subtle is, nonetheless, there.

Lactobacillus/Acidophilus is given to reseed the bowel in an attempt to counteract the diarrhea if I'm not mistaken. It's a food supplement, I think.

I know all about the diarrhea and C-Diff testing (worked in nursing homes a lot over the years). I had none stop diarrhea for the 6 months I was on chemotherapy along with terrible stomach cramps, a symptom that goes along with the diarrhea, but also with C-Diff. I had to give 3 specimens for C-Diff--all negative. Funny how the diarrhea went away when the chemo was over. Ha! Ha! Not.

[am0r803]

Again, THANKS!

Maybe I could bother you for one more thing! I need to do 3 interventions for my dx with the Impaired Tissue Integrity. All I could think of was turning and repositioning every 2 hours, and Keeping the area clean after EVERY episode of diarrhea due to the location. I'm not really sure where to go with the third one though. Maybe request one of those specialty mattresses to relieve pressure??

Just curious!

[Daytonite, BSN, RN]

Some ideas:

• Assess and document the length, width, depth, color and appearance of the wound daily
  
• Observe wound for signs of decreased tissue perfusion
  
• Assess for signs and symptoms of complications (infection, cellulitis, septicemia)
  
• Monitor and assess patient for pain in wound
  
• Record the amount, color, consistency and odor of any drainage daily or with each dressing change
  
• Clean wound and apply any dressings as ordered
  
• Apply a moisture barrier to skin around the ulcer
  
• Turn and reposition q 1-2 hours - do not slide patient when turning. Lift him instead to avoid shearing force.
  
• Use pillows to stabilize and positioning patient in good anatomical alignment
  
• Give special attention and protection to bony prominences when positioning patient
  
• Post a turning schedule at the bedside
  
• Use an air, gel or foam mattress for patients who are unable to turn themselves as well as those who are on a turn schedule
  
• Give active and passive ROM exercises
  
• Provide adequate hydration and nutrition - our dietitian was always putting our patients with any wounds on high protein diets if their renal status was OK

[nightmare, RN]

Daytonite,your care plans are always so informative.I have a couple of questions.Do you tilt patients in the US? This means that you do not turn them fully onto side by just by 30Degrees so that the pressure is taken off the affected area.If you use a proper slide sheet then patients can be slid without any shearing force used and it saves the staff from having to lift patients.

[Daytonite, BSN, RN]

Do you tilt patients in the US?

Yes, all the time. I got into trouble during the entrance exam for my BSN because I was asked to demonstrate turning a patient to their side and was failed because the examiner, who happened to be a full tenured PhD in Nursing, took a builder's level (can you believe that?) and declared the patient was not exactly 90 degrees with the mattress! It was a difficult nursing program with this professor around.

[nightmare, RN]

Oh I had some tutors like that!!