PROCEDURE 130 • Critically ill patients have multiple risk factors that increase the chance of pressure ulcer development. A valid and reliable pressure ulcer risk assessment tool should be used to assess a patient’s risk on admission and consistently throughout the hospitalization.1 • Patients with fecal incontinence and immobility are considered to be at increased risk of pressure ulcers.13,17,20 • Acutely ill patients are at high risk of fecal incontinence related to administration of a variety of mediations (i.e., antimicrobial, cardiovascular, central nervous system [CNS], and gastrointestinal agents),19 enteral feeding,2,22 disease processes (e.g., gastrointestinal, hepatic disease, spinal cord trauma, etc.), and enterotoxins (e.g., Clostridium difficile).2 • Personal protective equipment should be used when the source of the diarrhea is not identified, to avoid the possible spread of highly infectious organisms. • Urinary and fecal incontinence results in skin breakdown.5,6,8,22 Excessive moisture changes the skin’s protective pH and increases the permeability of the skin, decreasing its protective function. Fecal content is more irritating than urine because digestive enzymes in feces contribute to erosion of skin.13 • Perineal skin damage may progress rapidly and ranges in severity, presenting with erythema, edema, weeping, denuded skin, and pain.8,9,13,16,23 Other negative outcomes may include skin ulceration and secondary infection, including bacterial (Staphylococcus) and yeast (Candida albicans) infections that increase discomfort and treatment costs.8,13,15,16 • Incontinence-associated dermatitis (IAD) is inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin.9 IAD is the clinical term used to describe incontinence-associated skin damage. IAD often occurs in conjunction with pressure and shear and friction forces that precipitate pressure ulcers.9 • It is well established that excessive moisture and incontinence, especially fecal incontinence, significantly increases the patient’s risk of IAD and pressure ulcers; the research to guide fecal containment practice is limited.1–3,6,9,14,17,22 • Management of fecal incontinence should include the following elements: • An external fecal containment device adheres directly to the perianal skin, moving feces away from the skin and into a drainage container. The device can remain in place for 1 to 2 days without leaking.18 If the device is well adhered and not leaking, it may remain in place longer if clinically indicated. Care must be taken during removal of the device to prevent skin trauma or tears. • The general agreement in the literature is that the perianal incontinence pouch offers many advantages over diapers and balloon rectal catheters and is the least invasive method of fecal containment.11 • Some authors have recommended short-term management of fecal incontinence with devices intended for other purposes.14,
Fecal Containment Devices and Bowel Management System
PREREQUISITE NURSING KNOWLEDGE
Identification and treatment of the diarrhea. If the source of fecal incontinence cannot be eliminated, drug therapy may be used; however, the efficacy of these drugs is not known because randomized studies have focused on the management of chronic diarrhea in outpatients rather than acute diarrhea in hospitalized patients.22
Meticulous perineal skin care. Maintain clean, healthy skin by cleansing the skin with a pH-balanced no-rinse skin cleansing solution after each episode of diarrhea. Avoid soap and water. Most soaps are alkaline, and the skin’s pH is acidic (5.0 to 6.5); use of soap and water to cleanse the skin can further disrupt the skin’s protective properties.7
Apply a moisturizer with skin protectant. Moisturizers help hydrate intact skin, replace oils in the skin, and soothe skin irritation. Moisturizers that contain petrolatum, lanolin, dimethicone, or zinc can provide a protective barrier to protect and sooth denuded area.8,10
Use absorbent underpads that wick effluent away from the skin and allow for circulation of air between the patient’s skin and support surface. Avoid use of adult briefs and diapers that trap the moisture against the skin. Change underpads frequently.16
Consider application of a fecal containment device or bowel management system.
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130: Fecal Containment Devices and Bowel Management System
