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10.5.2 External Fecal Collector/Peri-Anal Pouch
Another option for external containment of frequent liquid stools is a fecal collector
(also called a peri-anal pouch) [11]. This product is a pouch with a ring-shaped
adhesive skin barrier that is cut to t around the anus. The external fecal collector
can be connected to a bedside drainage bag to collect liquid stool. Criteria for use of
the external fecal collector includes (1) the skin must be free of any skin products,
(2) skin is completely dry and intact before application, and (3) stool consistency
must be thin enough to drain into the pouch. It is imperative that the device be
applied promptly after diarrhea develops to keep the damaging effects of liquid
stool away from sensitive skin areas at high risk for irritant contact dermatitis due to
incontinence. The external fecal pouch is an effective containment method if correct
application is successful. Since the pouch is external, it is a conservative, non-
invasive method that facilitates infection control of loose liquid stool and has no
limit to how long it can be worn to manage diarrhea [34].
The United States Food and Drug Administration (US FDA) categorizes medical
devices according to their risk (Class I, II, or III) and the regulatory controls to
ensure their safety and effectiveness. Class I medical devices pose the lowest risk of
harm to the patient. The fecal pouch is a Class I medical device (very minimal
potential for harm) [13]. Other countries may have similar regulatory organizations
to the USFDA.
External fecal collectors do have several disadvantages. Patients who are ambu-
latory, agitated, obese (weight between buttocks negate stool ow) or have move-
ments that would dislodge the device or obstruct fecal ow (e.g., sliding up/down in
bed, sitting) may not be good candidates for external fecal collectors. It is essential
that there is close monitoring to ensure intact placement and functioning of the
device as any stool leakage defeats the rationale for diverting the liquid feces away
from the skin. An external fecal collector should not be used on denuded skin, moist
or skin that has product (e.g., emollients, protectors) as the adhesive will not adhere
securely enough to maintain operational function of the device. If there is minimal
denudement at the peri-anal area, ostomy stoma powder may be applied lightly to
the denuded area to facilitate adhesion of the external fecal collector. If leakage
occurs because the external fecal collector adhesive seal is not intact, the skin
becomes directly exposed to the irritating effects of liquid stool resulting in irrita-
tion and/or denudement. Staff applying the device must be educated on correct
application, trouble-shooting, removal, and maintenance. When external fecal col-
lectors fail, it often is due to unsuccessful adhesive adherence or patient movements
that dislodge or obstruct the device functionality. Another limitation of the external
fecal collector is that any procedure that requires access to the rectum (e.g., rectal
medications, examinations) cannot be performed unless the external fecal collector
J. Pittman and T. Beeson
205
Table 10.4 External fecal collector application checklist
Task
Check if
completed
1. Obtain equipment and explain procedure to patient/family
2. Position the patient in left lateral side-lying position with knees drawn
toward chest (if possible). If required, remove old fecal incontinence
collector by slowly peeling wafer from one edge until all areas are free from
skin and discard
3. Cleanse perineal area. Pat to dry. Assess skin integrity
4. Estimate the size needed for the anal opening in the fecal collector skin
barrier. Cut the skin barrier opening
5. Apply skin sealant if needed to perianal skin
6. Remove backing from fecal collector. If desired, apply a small amount of
ostomy paste around the opening on the skin barrier
7. A staff member should separate the buttocks to expose the anal opening.
8. A second staff member should fold the opening of the fecal collector to the
center and apply to one side of the perianal area and buttocks following the
convolution of the area and then apply to the other side of the perianal area
and buttocks. Hold hand over skin barrier and fecal collector for 30–45s to
promote adhesion
9. Consider “picture framing” the skin barrier’s edge with colored tape as
needed
10. Connect external fecal collector drainage port to a bedside drainage bag and
empty every shift. Document procedure and output in patient’s medical
record
Used with permission of Indiana University Health © 2024
is removed and a new one reapplied. Application steps and checklist that may assist
the nursing staff to ensure placement and adherence of the external fecal collector
are listed in Table10.4.
10.6 Indwelling Tubes forCollection
There are a variety of indwelling bowel catheters and bowel management systems
that will collect liquid stool. Selection requires clear criteria for use that is deter-
mined by assessment of an individual patient’s need. As with any indwelling tube
system that is anchored through the use of an inatable balloon, there must be intact
anatomical structures through which the tube is inserted and where the balloon will
be inated without causing circulatory obstruction or prevent liquid stool from leak-
ing out. Invasive devices should be used judiciously because of their limitations,
contraindications, precautions, and unanswered questions about long-term effects
[35]. A comprehensive bowel management and education plan is imperative to suc-
cessfully manage the critically ill patient with fecal incontinence [1, 36].
10 Management of Fecal Incontinence in Acutely Ill and Critically Ill Hospitalized…
206
10.6.1 Fecal/Bowel Management Systems
Fecal or bowel management systems are closed-system catheters that are made of
non-latex (silicone) material inserted through the anus into rectum and secured with
a low-pressure inatable balloon that is lled with water or air. Stool ows by grav-
ity through a long external drainage tube into an external collection bag. These
internal bowel management catheter systems are medical devices that are primarily
used for hospitalized critically ill patients who are bedbound and have liquid/loose
stools. These internal fecal catheters aim to prevent liquid stool from making con-
tact with the skin and the spread of infectious stool. These fecal catheter systems
have a lumen for installation of medications and irrigation of the rectum [35, 37, 38].
Each manufacturer provides specic indications, contraindications, use instruc-
tions, complication alerts, and recommendations for their specic product.
Fecal or bowel management systems are contraindicated in patients who have
had recent lower large bowel or rectal surgery, rectal or anal injury, stricture or ste-
nosis, mucosal impairment, rectal/anal tumor, or severe hemorrhoids are not candi-
dates for these devices. In addition, see manufacturer recommendations for
additional contraindications for using a bowel management system. A physician or
nurse practitioner order is required before inserting any of these indwelling devices.
See Table10.5 for an example set of orders for fecal/bowel management system.
Nurses are typically the clinicians who insert, maintain, and remove these
devices. Each brand of fecal/bowel catheter system has its own design for ease of
insertion and prevention of discomfort on insertion. Each brand has its own way of
controlling odor and collection bag usage instructions. Odor-controlling devices are
imbedded into the collection bags as these bags are single use only.
Device-specic education, knowledge, and skill competency are requirements
for any staff that will be using this type of device. It is important that a digital rectal
exam be done rst to assess whether the liquid stool may be caused from bypassing
impacted feces. Any impacted feces must be cleared before using this type of device.
The retention balloon is designed to be low pressure, reducing the risk of anorectal
trauma. Additionally, if the patient should expel the device or it is accidentally
pulled out, the risk of rectal trauma is minimized and the catheter can be re-inserted.
Maintenance of the device involves checking for patency and leakage on a regular
schedule, irrigating the catheter to maintain patency as needed, and inspecting the
perianal skin for any injury [35]. Documentation should include the cuff ination,
stool consistency, volume, skin integrity, and the assessment of ongoing need for the
device. Box 10.1 lists important steps for insertion and management of one of these
systems.
J. Pittman and T. Beeson
207
Table 10.5 Example of an order set for using a fecal/bowel management system
Date
Time
Physician orders
Assessment
Initiate bowel management (BM) program policy for management of fecal
incontinence
Refer to bowel management program policy and fecal incontinence/BM decision
tree for guidelines regarding choosing appropriate bowel management method
NOTE: Non-invasive stool division (e.g., fecal incontinence collector) should be
attempted rst if clinically able
CONTRAINDICATIONS to internal bowel management method: Bowel
management system (BMS) or rectal trumpet
Loss of sphincter tone, under 18years of age, allergy to silicone
Impacted/formed stool- must be resolved prior to insertion
Undiagnosed abdominal distention, nausea, vomiting, gastrointestinal
bleed, small bowel obstruction, ileus
Anorectal strictures, tumors, anal reconstruction to sphincter or rectal
anastomosis within 6weeks
Distal rectum unable to accommodate 40ml retention cuff (for BMS)
Usual care method
Skin barrier protection for prevention of irritant contact dermatitis
due to incontinence
Dimethicone cleansing/barrier wipes or
Dimethicone-based barrier cream
Skin barrier protection for treatment of irritant contact dermatitis
due to incontinence
Zinc based barrier cream. Apply liberally with each
incontinence episode
Do not “rub off” after cleansing—Reapply to any exposed areas
Fecal incontinence collector pouch, apply to peri-anal skin
Rectal trumpet method
Perform digital exam to evaluate for impaction and rectal tone
Digitally remove any impacted stool from rectal vault
Insert rectal trumpet following procedure guidelines in bowel
management program policy
Notify clinical nurse specialist (CNS)
Notify wound ostomy continence (WOC) team
BMS—maximum duration 29days
Perform digital exam to evaluate for impaction and rectal tone
Digitally remove any impacted stool from rectal vault
Insert bowel management system (BMS) following procedure
guidelines in bowel management program policy
Irrigate BMS over 10min with □ 300ml □ 500ml lukewarm
water every 8–12h to maintain patency of tubing
Notify CNS
Notify WOC team
Assess peri-anal skin daily for irritation, denudement, leakage,
and pressure ulcer development
Adapted and used with permission of Indiana University Health © 2024
10 Management of Fecal Incontinence in Acutely Ill and Critically Ill Hospitalized…
208
Fecal/bowel management systems are advantageous because they address many
care goals. The devices can remain in place for up to 29 consecutive days without
being changed. However, as with any internal device, there is always the risk for
potential adverse events when using fecal/bowel management systems. A 3% inci-
dence of gastrointestinal hemorrhage in which patients required replacement of
packed red blood cells has been reported in one intensive care unit [39]. Rectal ero-
sion and stula formation are other complications [40, 41]. The advanced practice
nurse should unsure that nurses perform meticulous, strict and timed monitoring
documentation to help decrease adverse events from occurring.
10.6.2 Rectal Trumpet
For patients that have liquid fecal incontinence, there is an additional method of
management, referred to as a “rectal trumpet,” which consists of the insertion of an
8mm nasopharyngeal trumpet into the rectum [42, 43]. The nasopharyngeal trum-
pet is inserted with the ange as the anchor into the rectum. The shaft end of the
trumpet is attached to a urinary drainage collection bag and secured with tape. The
rectal trumpet is positioned in a downward direction to avoid tension on the trumpet
Box 10.1 Key Steps for Insertion and Maintenance of a Fecal/Bowel
Management System
1. Properly position the patient so the rectum can be well visualized (typi-
cally on the left side) during insertion.
2. Lubricate the balloon end of the catheter for ease and comfort of insertion.
3. Inate the balloon per manufacturer’s instructions and never over-
inate it.
4. Position the external part of the catheter so as to avoid kinks and obstruc-
tions; regularly check the catheter for patency.
5. Avoid tugging on the catheter to prevent damage to the anal sphincter and
internal mucosa from the inated balloon.
6. Maintain the drainage bag below the patient to facilitate ow of feces by
gravity.
7. Use the correct port/lumen for irrigating the rectum or instilling
medications.
8. Regularly assess the skin around the catheter for seepage/leakage of feces
and skin damage and treating skin damage as needed (see Chap. 14).
9. Monitor the patient to avoid tugging or removal of the catheter.
10. Deate the balloon prior to catheter removal.
Used with permission of Indiana University Health © 2024.
J. Pittman and T. Beeson
209
Is the patient’s skin surrounding the rectum
denuded so as to prevent use of external fecal
incontinence collection pouch?
Has the patient failed external fecal
incontinence collection pouch use?
Has rectal trumpet failed or is stool too thick for
passage via rectal trumpet?
Provider order to insert rectal trumpet
Does the patient have any of the following
contraindications?
· Suspected or confirmed rectal mucosal
impairment
· Rectal surgery within the last year
· Rectal or anal injury
· Hemorrhoids of significant size and/or
symptoms
· Rectal or anal stricture or stenosis
· Suspected or confirmed rectal/anal tumor
· Other in-dwelling rectal or anal device
· Sensitive to or who have had an allergic
reaction to any component within the system
Does the patient have poor rectal tone?
Does the patient have fecal impaction?
Yes
Apply external fecal
incontinence collection pouch
Continue Rectal Trumpet
Need Provider order for IBBC device.
Does patient need medications or
enemas via IBBC? (as prescribed by
physician/provider)
Continue usual care; do NOT
insert any internal fecal device
.
Need Provider order for
IBBC *device Do not insert
rectal trumpet.
Need Provider order to
remove impaction; re-evaluate
Apply external fecal
incontinence collection
pouch
Fig. 10.1 Fecal incontinence containment decision tree. Fecal incontinence decision-making
algorithm for insertion and use of an IBBC* and rectal trumpet. Adapted and used with permission
of Indiana University Health © 2024. Final judgment about the propriety of any clinical practice
rests with the health care provider). *IBBC Indwelling balloon bowel catheter
[42]. Figure10.1 presents an example algorithm for insertion and use of a rectal
trumpet and bowel management system. Regarding adverse effects of use of a rectal
trumpet, there was a 3% incidence of rectal trumpet-associated hemorrhage requir-
ing transfusion with packed red blood cells among patients in a single transitional
care unit [44]. Although there is some limited evidence to support the use of a nasal
trumpet as a fecal collection device [43], this is an off-label indication for usage of
10 Management of Fecal Incontinence in Acutely Ill and Critically Ill Hospitalized…
210
this device, and the judgment and responsibility for its use rests with the healthcare
provider.
10.7 Pharmacologic Treatment
When a critically ill patient has fecal incontinence, it is important to determine
the cause in order to prescribe the correct treatment, i.e., whether fecal inconti-
nence is disease-related, medication-related, or diet-related. In disease-related
diarrhea, usually eliminating the trigger leads to resolution. In medication-related
diarrhea, identify the medication. Sometimes laxatives or prokinetics may be the
culprit and should be eliminated when the indication for their use is not present
anymore. Antibiotic-associated diarrhea (AAD) incidence is up to 25% and
depends on the medication. AAD is classied as AAD without colitis or AAD
with colitis (induced by C. difcile or Klebsiella oxytoca). Severe diarrhea in the
immunocompromised patient occurs in up to 10% of individuals. In diet-related
diarrhea, it is commonly reported as a complication of enteral nutrition. Enteral
tube feeding may cause diarrhea due to various reasons such as the most common
one known as “Dumping Syndrome” (too fast a transit through the bowel). It is
important to work with the registered dietitian to manage the feedings and
achieve the required nutritional intake. The dietician is a crucial part of the team
and can provide soluble bers or other additives to the enteral feeding plan [45].
Identifying an enteral feeding formula that is better tolerated or possibly slowing
down the rate of administration should be tried before considering any anti-diar-
rheal medications.
Fecal incontinence can also be infectious or non-infectious. As with any drug
therapy, it is essential to target either the causative organism, disease, or have a clear
pharmacological goal with measurable outcome. For example, if the causative
organism is C. difcile, then appropriate antimicrobial therapy (e.g., oral metronida-
zole or vancomycin) would be the expected physician/nurse practitioner’s order.
However, if the presenting symptom is intestinal transit time that is too fast with the
need to reduce intestinal peristalsis slowing transit time, anti-diarrheal medications
(e.g., loperamide) may be ordered. When transit time is slowed, it will also decrease
elimination urgency and frequency to enable the anal sphincter to respond more
adequately. The caution is not to overdose or overuse anti-diarrheal medications as
they can lead to constipation, megacolon, and central nervous system side effects.
Bulking agents (e.g., psyllium) may be used to help rm the stool so that it is not as
liquid. Adding more insoluble and soluble ber to the diet may also act as a bulking
agent. Collaborating with the registered dietitian on diet modications is recom-
mended. Irrigation of water through the fecal/bowel management system may also
result in a more liquid stool to ensure patency for drainage (Blaser etal. 2015).
When the treatment goal is to have the patient’s stool be either liquid or semi-
formed in order to be able to use a fecal/bowel management system, the pharmaco-
logical approach may include a combination of a cathartic stimulant (e.g.,
J. Pittman and T. Beeson
211
senna-based product, bisacodyl) and osmotic laxative (e.g., lactulose, polyethylene
glycol powder).
10.8 Prevention ofFecal Incontinence
Nurses are pivotal to preventing the development of transient fecal incontinence
while patients are in acute or critical care. Furthermore, nursing care has a direct
impact for those patients who come to hospital with chronic fecal incontinence.
Increased illness burden, for example, from skin breakdown, infections and psycho-
logical stress, can be directly correlated to fecal incontinence. Therefore, preventive
care interventions are as much as a priority as managing fecal incontinence for this
vulnerable population. The advanced practice continence nurse promotes preven-
tion of fecal incontinence (see Box 10.2).
Box 10.2 Interventions for Prevention of Fecal Incontinence in Acutely or
Critically Ill Hospitalized Patients
• Monitor uid intake to ensure adequate hydration to prevent constipation.
• Mobilize and/or ambulate patients at least 2–3 times a day to stimulate
bowel peristalsis.
• Monitor food intake paying attention to ber intake to ensure a regular pat-
tern of elimination of a formed stool. Referral to a registered dietitian as
needed. Possible addition of a fruit-based laxative (30mL) daily. If the
patient’s glomerular ltration rate (an indication of kidney function) is less
than 30mL/min, fruit-based laxative is contraindicated.
• Provide privacy when patient is toileting. An odor-reducing deodorizer can
be used if noxious odor is present.
• Ensure correct positioning of patient on the toilet or commode (thighs at
30° to buttocks). This may require a foot stool that the patient plants their
feet on. Commodes placed over the toilet are of particular concern because
they are high and often result with the patient’s feet dangling rather than
being supported.
• Protect vulnerable peri-anal skin from urine and stool. This includes
impeccable perineal cleansing, timely changing of collection/containment
products, and application of appropriate skin protectants (see Chap. 14).
• Routinely ask the patient after breakfast whether they need to toilet. This
timing takes advantage of the gastrocolic reex after meals.
• Complete and review the bowel record every shift in order to detect early
if a problem is arising.
Adapted from and used with permission of Indiana University
Health © 2024.
10 Management of Fecal Incontinence in Acutely Ill and Critically Ill Hospitalized…
212
The primary nurse for the patient should ensure the implementation of a conti-
nence care plan that includes assessment and interventions from the occupational
therapist, physiotherapist, pharmacist, registered dietitian.
10.9 Expected Patient Outcomes forFecal Incontinence
inAcute Care andCritical Care
The expected successful patient outcome for transient and/or chronic fecal inconti-
nence is that at discharge, the patient’s bowel function returns to their usual base-
line. Patient teaching on good bowel hygiene practices would include adequate
intake of non-caffeinated uids, intake of adequate soluble and non-soluble ber,
and walking or exercising after a meal to engage the gastrocolic reex. Additionally,
emphasizing that when the urge to defecate is felt, it is important to respond in a
timely manner as delaying may result in fecal incontinence. Proper positioning on
the toilet with the upper legs at a 30° angle to the buttocks, feet at on the oor (may
need a small foot stool under the feet to achieve this angle) enables the external anal
sphincter to relax. Additionally, trying to set a daily routine that ensures adequate
time to completely evacuate. The use of laxatives or suppositories should be used
with caution and a discussion with their primary care physician or advanced prac-
tice nurse is advised.
For patients that have an ongoing problem with fecal incontinence at discharge,
a referral to a nurse continence specialist, continence service in the community or
advanced practice nurse either in the hospital or community is recommended. These
nurses and/or services have additional evidence-based knowledge and skills to
assess, diagnose, and conservatively treat fecal incontinence [46]. Furthermore,
they are able to determine if referral to another healthcare providers may be helpful
or, if an advanced practice role that includes prescribing and ordering of lab and
diagnostic imaging tests, may undertake further investigation or referral [47].
10.10 Summary
Fecal incontinence in acute and critical care patients is often a complex and chal-
lenging problem for the patient and their caregivers. Nurses in all positions of care,
from the direct care bedside nurse, wound ostomy continence (WOC) nurse or nurse
continence specialist, to the advanced practice nurse, have a major role to play in
preventing the development of fecal incontinence, and associated skin injury and
infections. However, when fecal incontinence is present, it is imperative that nurses
are knowledgeable and have the requisite skills to develop and carry out an appro-
priate fecal incontinence management plan. Furthermore, the direct bedside care
nurses are the 24/7 professionals who have the most consistent contact with the
patient and thus observe what is needed, provide the appropriate intervention,
J. Pittman and T. Beeson
213
evaluate the effectiveness of the interventions, and implement a change in the
approach. WOC nurses and advanced practice nurses may recommend or order the
plan of care, provide consultation, and monitor the patient’s response. These nurses
also educate the general/bedside nursing staff and facilitate system changes that
enable improvements to the care for patients with fecal incontinence. This may
include selecting and evaluating products and devices for the management of fecal
incontinence, development of best practice clinical guidelines for fecal inconti-
nence, and development of protocols and documentation requirements and records
for fecal management systems.
Ultimately, the goal for patients with either transient or chronic fecal inconti-
nence in acute and critical is to prevent what is preventable; reverse what is revers-
ible; and better manage what is not changeable.
Boxes 10.3 and 10.4 present example case studies for managing fecal inconti-
nence due to common problems in hospitalized patients.
Box 10.3 Case Study 1: Hospitalized Patient Infected with C. dicile
Sam was a 67-year-old male with pancreatic adenocarcinoma post Whipple
complicated by a gastrojejunostomy leak who was discharged with a PICC
(peripherally inserted central catheter) for antibiotic coverage and total paren-
teral nutrition. Sam was readmitted for failure to self-manage wound and
drain at home requiring several clinic visits. Upon admission, Sam reports
fever and fatigue at home. Blood cultures collected on admission grew
Candida auris and Candida albicans so is continued on antibiotics. His PICC
was removed and a drain replaced in interventional radiology.
Sam becomes hypotensive and transferred to the intensive care area. Three
days later, he is transferred to a progressive care/step-down unit where he
begins reporting nausea and vomiting. Several days later, he develops diar-
rhea, and the chart shows seven loose stools. He was then started on relizorb.
His white blood count (WBC) was increasing, tube feeds were at goal rate,
and he was reporting continuous diarrhea. Loperamide was initiated to control
the diarrhea. In order to preserve Sam’s skin, the bowel management algo-
rithm was initiated with an external fecal incontinence collector. The volume
of liquid stool documented was 550 and 600ml over the next 2days. A fol-
low-up computerized tomography (CT) scan showed colitis. The next day he
deteriorated and was moved back to the intensive care unit with low blood
pressures. Sam was tested for C. difcile at this time which came back toxin
positive, treatment was then initiated. Nursing was having difculty at this
time keeping the external fecal collector intact. It was then decided to advance
to an internal bowel management device as the stool was too thick to ow
through the rectal trumpet. Skin protection creams were applied as the inter-
nal bowel management devices have a tendency to leak stool. Sam stayed in
the intensive care unit for several days until he was stable enough to transfer
to a long-term nursing care facility for ongoing care of his wound and drains.
10 Management of Fecal Incontinence in Acutely Ill and Critically Ill Hospitalized…