Which cue would prompt the nurse to select a hypothesis of bowel incontinence for a patient?

What Is Soiling and Fecal Incontinence?

Fecal incontinence (accidentally having bowel movements) is a very common problem in children. It can be caused by medical conditions like chronic constipation or congenital conditions that may disrupt bowel control, including:

• Spina bifida
• Anorectal malformations
• Hirschsprung disease

Fecal soiling can cause children intense embarrassment and social problems, and can be frustrating for both parents and children. The good news is that with patience, encouragement and the right treatment, most children can develop good bowel control and live normal lives.

There are two types of fecal incontinence:

• True fecal incontinence occurs in children who do not have the normal mechanisms needed for controlling their bowel movements. Typically, these children have:
  • Anorectal malformations (imperforate anus)
  • Hirschsprung disease
  • Spinal problems

  These conditions may have prevented their bodies from developing normal bowel structures or control of those structures. While surgical repair can help restore bowel function, it cannot always insure bowel control. Children with true fecal incontinence can also be classified as having a slow or fast bowel – and the treatment for each is different.

  Through a bowel management boot camp or surgery, children can successfully manage bowel movements and avoid soiling.

• Pseudoincontinence or encopresis typically occurs in children with the ability to toilet train but who have developed severe, chronic constipation. This leads to stools that are infrequent or hard to pass.

  It can also occur in children with anatomical abnormalities that predispose them to developing constipation.

  While most of these children have the ability to control their bowel movements, they become so constipated that stool impacts and overflows. Treatment is focused on preventing constipation and can be done through:

  • Diet
  • Medications

There is also a promising new therapeutic modality for pediatric urinary and fecal incontinence, and chronic constipation in children when all other treatments have been unsuccessful. Sacral nerve stimulation (SNS) technology can be compared to a pacemaker for the heart, but provides stimulation to the anal canal area and lower part of the colon and the bladder.

While a few other children’s hospitals in the United States offer sacral nerve stimulation based on subjective criteria and clinical symptoms, Nationwide Children’s is one of the first to formally structure this therapy by evaluating objective bladder and bowel function studies before and after the procedure to assess treatment response.

How Does Continence Work?

When it comes to eliminating feces (solid waste), the body goes through a series of complicated processes which depend on:

• Voluntary muscle control
• Sensation
• Involuntary movements of the colon that push stool along

Toilet training and bowel control are only able to happen when these three things are working together properly.  An issue with just one part of the process can lead to bowel problems like constipation or fecal incontinence.

Voluntary Muscles

Once the large intestine has pushed stool to the anorectal area, sphincter muscles that control feces leaving the body are used. Children are able to voluntarily control those muscles to hold stool, or relax the muscles to go to the bathroom. Sometimes these sphincter muscles can be weak in children born with an anorectal malformation/imperforate anus or spinal problems. If a child chooses to hold stool too often, it can lead to chronic constipation.

Sensation

In order to know when to use sphincter muscles, the child must first feel something in the area, a sensation provided by the anal canal.  This part of the body provides detailed sensory information to the brain to let it know when it’s “time to go.”

Surgery can reduce sensation in the anal canal when correcting:

• Anorectal malformations
• Hirschsprung disease
• Certain types of spinal problems

Because of this, the brain does not get the message when the rectum is full of stool.

Motility (Slow or Fast)

Bowel issues can also be triggered by how fast the colon pushes feces through to the rectum before it reaches the sphincter muscles.

Hypomotility: In patients where the colon pushes stool slowly, feces tends to gather in the rectum – which is larger than normal in most such patients. These children may not be able to feel the fullness, developing severe constipation and then soiling due to overflow. The issue can also develop in children who don’t have any malformations and have never had surgery. In this case, the soiling due to idiopathic (unknown cause) constipation is called encopresis. Treatment for these patients with slow motility can involve:

• Diet changes
• Medication
• Treatments
• Bowel management programs

Hypermotility: Patients who may have had surgery that removed parts of their colon experience stool that moves through too fast. This can result in loose, watery stools that can leak out of the anus. Treatment for this may involve diet modifications and medication.

Which cues support the nurse formulating a hypothesis of constipation for a patient?

Which is a defining characteristic of the nursing diagnosis bowel incontinence?

What is bowel incontinence related to?

What should the nurse suggest to a client to assist with regular bowel movements?