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                        CLINICAL PRACTICE GUIDELINES

Number:                                                               EQuIP Number:

TO :                           All Staff

SUBJECT :                      Management of Diarrhoea
Date Effective:
Reg. Authority:                Executive Director, Nursing Services
Date Revised:
Date for next review:
Review Responsibility:         Nursing Practice Committee

1. Maintenance of a realistic and acceptable elimination pattern for each patient/resident of
   BHS. (The patient or resident is free of preventable bowel complications during
   admission/stay in BHS)

2. There is timely identification of those at risk of developing bowel elimination problems.

3. Where a bowel problem exists, it is identified and treated/managed safely and effectively.

4. The patient/resident is knowledgeable about their bowel management

Treatment and management of any person with diarrhoea is based on a thorough individual
assessment and the rationale for treatment and management are clearly documented.

Defining diarrhoea
Diarhhoea is a change from normal bowel habit involving an increase in the amount, frequency
and/or fluidity of bowel actions. It is often associated with urgency, perianal discomfort and

Acute diarrhoea usually lasts less than 2 or 3 weeks and is usually mild and self-limiting,
although it can be an overwhelming and life threatening condition. Frequent causes of acute
diarrhoea include dietary factors (ie too much fruit or alcohol), allergies, or infective causes (such
as gastroeteritis or food poisoning). Medical treatment of acute diarrhoea will depend on the
severity of the illness and its underlying cause. Hospitalization may be required for acute
diarrhoea associated with sepsis, severe dehydration or for those with an impaired immune

Chronic diarrhoea generally lasts longer than 2 or 3 weeks and may be caused by factors such as
Inflammatory Bowel Disease, malabsorption, organic disease such as neoplasms or diverticulitis,
endocrine disorders or colitis such as may result from chemotherapy or radiation therapy.

Diarrhoea or impaction with overflow?
The loose, watery stools that may occur with faecal impaction with overflow may be mistaken for
diarrhoea. To determine if the person is impacted, carrying out abdominal palpation and a rectal
examination may reveal a loaded rectum and lower colon. However, the loading may be at a
higher level in the colon which will not be detected by a rectal examination. Medical staff may
order a plain abdominal x-ray to confirm the presence of loading or determine the presence and
level of loading if diagnosis is still not clear after taking a history and doing an examination.


           PROCESS STANDARDS                                   KEYPOINTS
 1. Maintain adequate hydration
 • Encourage frequent intake of small          •   Salty soups and fruit juice will usually
     amounts of oral fluid if nauseous             supply the sodium, potassium and
 • Offer fluids and encourage the person           glucose necessary (Talley & Martin,
     to drink a normal fluid intake                1996)
 • I.V. fluids may be used in severe           •   Avoid milk drinks (see below)
 2. Maintain normal dietary intake as
 appetite and nausea will allow
 • Restrict milk and milk products             •   Limiting food intake only serves to
 • Avoid foods that might exacerbate the           restrict calorie intake. However it is
     diarrhoea such as those containing            advisable to restrict milk and milk
     sorbitol                                      product intake as a secondary lactase
 • Offer food within these limitations that        intolerance during the episode of
     are appetizing to the patient                 diarrhoea is common.
 3. Anti-diarrhoeal agents may be              •   These agents offer effective
 prescribed as appropriate by medical staff        symptomatic relief
 4. Provide adequate access to the toilet
 • Provide ensuite access or make a            •   People often find using their bowels
     commode available for use in the room         difficult and embarrassing when they are
     if required                                   out of their home environment.
 • Ensure assistance is available quickly          Episodes of diarrhoea are often frequent
     as required if patient unable to get to       and urgent. Access quickly and as often
     toilet independently                          required to a private, clean toilet will
 • Ensure adequate privacy & safety while          help reduce anxiety and embarrassment.
     using the toilet
 • Ensure adequate toilet/commode
     cleaning and odour control strategies
     are in place
 5. Maintain skin integrity                    Skin integrity is threatened by contact with
 • Assist with adequate personal hygiene       faecal fluid/material and frequent wiping
    including opportunity to wash after               with toilet paper and possible incontinence.
    each bowel motion if required
 • Provide moist skin wipes for use as
    required rather than dry toilet paper
 • Provide skin barrier products as
    necessary to protect the peri-anal skin
 • Change clothing as often as required to
    keep perianal area dry and fresh
 • Provide a supply of an appropriate
    incontinence pad if continence is
    compromised by the diarrhoea
 6. Maintain universal infection control              The acute episode may be infective in origin
 precautions when assisting patient
 7. Manage other symptoms as required                 Fever may be part of the symptoms if the
 • Fever                                              diarrhoea is caused by infection
 • Abdominal pain, cramping & bloating

Emmanuel, ?, 2001, Bowel Care in Frail Older People - Consensus Workshop, Royal College of Physicians, London,
20 June, unpublished consensus paper

Mallet, J., Dougherty, L. (eds), 2000, The Royal Marsden Hospital Manual of Clinical Nursing Procedures,
Blackwell Science:U.K.

Talley, N.J, Martin,CJ. 1996 Clinical Gastroenterology: A practical problem-based approach, Maclennnan & Petty:
Nursing Practice Guideline             2003
                                       Ballarat Health Services

To:                                    All Staff
Subject:                               Management of Faecal Incontinence
Date effective:
Date revised:
Date for next review:
Review responsibility:                 Nursing Practice Committee

The person with faecal incontinence has a right to thorough assessment of the problem in order to
treat and cure the incontinence or to enable social continence through appropriate management.

The person’s faecal incontinence is resolved or managed effectively

Faecal Incontinence is the loss of bowel control and can have significant physical, emotional and
social consequences for the sufferer. The loss can involve gas, fluid matter or solid stool.

To be continent of faeces a person requires:
• An intact and functioning anal sphincter
• Intact and functioning sensory nerve endings in the rectum and anus
• Normal stool consistency
• A rectum that is functioning normally and able to stretch and store faecal matter in between
   regular bowel motions

Because of the nature of the problem, faecal incontinence reduces a person’s self-confidence, can
severely restrict lifestyle and cause social isolation. Due to the embarrassment and stigma
associated with it, people with faecal incontinence may not have told anyone that they have the
problem. A person with faecal incontinence requires a supportive and accepting manner from
health professionals, carers and family members.

Faecal incontinence is a common condition. It is estimated that between 6-10% of the population
are affected. It is caused be a variety of underlying bowel and neurological disorders as well as
from lifestyle choices made by the individual. The key to successful treatment and management
is the identification of the cause of the problem for each person. It may involve changing
lifestyle factors (such fluid and dietary intake and toileting patterns), conservative options such as
the modification and use of medication, use of bio-feedback & electrical stimulation to
rehabilitate the sphincter, through to a number of possible surgical procedures. If after nursing
assessment there is no obvious cause identified that can be improved with nursing management,
medical assessment is required. A specialist medical referral may be required.
The bowel pattern of each patient or resident should be screened by nursing staff on admission.
If there are any concerns or a problem is reported or identified, complete the Bowel Elimination
Assessment Form (MR/#) and Observation Chart (MR/#) prior to commencing any management
strategies. Refer to the BHS Nursing Protocol for Assessment of Bowel Elimination.

When assessing faecal incontinence it is important to describe the exact nature of the
incontinence. This includes what the loss involves (ie fluid, solid, amount) and when it occurs
and how long it has been present (does it date from a particular event – eg. perianal surgery or a
difficult vaginal delivery).

A physical examination will include:
 • Inspection of the perineum and anal region for soiling, excoriation of the skin and any
    obvious abnormality such as prolapse external to the anus or a gaping/loose anal opening
 • Digital rectal examination noting the state of the anal sphincter and the presence of any mass
    in the rectum.
 • Abdominal examination – including palpation and auscultation to note whether normal
    bowel sounds are present and if there are any abdominal masses or other signs of faecal

 From the assessment:
 • Identify underlying causes if possible. This includes a review of current drug therapy.
 • Liaise with the person’s medical officer re the outcome of the assessment
 • Develop a management/care plan in conjunction with the person as appropriate
               PROCESS                                       RATIONALE

Step 1:     Deal with underlying causes if possible
Exclude underlying causes                 • Treatment of the underlying cause may resolve
                                                   the faecal incontinence
                                               •   Serious underlying causes need to be identified
Review medications
• Refer to medical officer for review of       •   Many common drugs may cause the incontinence
   drugs in view of identified incontinence

Step 2:      Educate the Person
Explain ‘normal’                               •   Person may be reporting perceptions not real
Make goals of management clear                    •   Education and lifestyle advice may control
                                                      symptoms in many cases
Don’t put off using bowels if has the urge        •   Suppression of urge can reduce gastric transit
to defecate

Step 3:               Keep stool at a soft, formed consistency
Sufficient fluid intake                     There is no evidence that excessive fluid intake
• 1.5-2.0 litres/day unless contraindicated improves bowel function. However, a reduced fluid
                                                  intake can result in a harder stool and may lead to
                                                  constipation, so a daily fluid intake of 1.5-2.0 litres is
                                                  required to avoid this.
                                                  • Fibre creates stool bulk and also draws fluid into
Adequate dietary fibre intake                          the stool, making it bigger and softer. The
                                                       bigger stool stretches the rectum and stimulates
• 20-30grams of dietary fibre/day is                   the bowel reflexes to move. The stool being
   recommended                                         softer is easier to move along and out.
• a trial of fibre supplement such as his         • Increased fibre is effective in some people and is
   psyllium husks or benefibre in diet or by           a relatively safe and cheap therapy to trial
   using a commercial preparation (eg.            • Not to be used in people with inadequate fluid
                                                       intake and those who are immobile
   Metamucil) could be indicated
Use of laxatives as required                      •   The faecal incontinence may be a result of
• Choice can be guided by laxative                    impaction with overflow
                                                  •   over-use of laxatives or use of the inappropriate
   guidelines in protocol for Management              laxative may cause faecal incontinence
   of Constipation                                •   softener laxatives particularly need to be use
• Laxatives need to be used with caution              cautiously in the elderly. An over-soft stool can
                                                      contribute to incontinence by being not solid
                                                      enough to stretch the rectum resulting in under-
                                                      stimulation of the defecatory reflexes and
                                                      retention and build up of stool. A very soft or
                                                      watery stool is also problematic if the person has
                                                      a compromised anal sphincter.

Step 4:                Establish bowel regularity
• At times to make use of the gastro-colic • A reflex mass movement of the bowel is
                                                triggered by the filling of the stomach with food.
   reflex ie toileting within half an hour of   The bowel contents are moved down and into the
   a meal                                       rectum, stretching it and creating the sensation of
• Toilet at regular times                       urge to evacuate the bowels
• Allow plenty of time for toileting          • It is possible to predict therefore that a person
                                                      may well need to evacuate their bowels after a
                                                      meal because of this reflex
                                                  •   Allowing time on the toilet will help ensure
                                                      complete evacuation
Step 5:               Facilitate bowel evacuation
 Position                                  • This position creates a better pelvic angle for
• Best position for toileting is feet well    evacuation and helps promote best possible
                                              emptying of the rectum
   supported and leaning slightly forward  • Footstool and leaning forward to be used
   with forearms resting on knees             cautiously in people following orthopaedic
• Ensure feet well supported on the           surgery to the pelvic area
   ground or on a small footstool          • Care needs to be taken to ensure the footstool
• Use toilet rather than commode or pan       will not be a hazard for tripping
                                           • Sitting upright on a toilet or commode creates a
   wherever possible
                                                    better pelvic angle for evacuation than lying on a
                                                •   A toilet also provides a more private
                                                •   The incontinence may be best managed by using
Using prescribed bowel therapies                    a regular, predictable and manageable bowel
                                                    action eg. through the use of a regular regime of
• Suppositories/enemas                              suppositories or use of digital rectal stimulation
• Digital rectal stimulation                        to trigger the defecation reflexes at a suitable

Step 6:               Managing/containing faecal loss
Use of appropriate continence products     • Containment of the faecal incontinence using an
This could include use of                    appropriate device will minimize skin
                                             complications, reduce odour and help a person to
• Incontinence pads                          be socially continent. The Continence Nurse
• Anal plugs                                 Consultant will be able to assist in the selection
• Faecal drainage bags                       if required.
Ensuring maintenance of skin integrity     • Skin integrity is compromised when it comes in
• Adequate perineal/perianal hygiene after   contact with faecal matter. A barrier product
                                             minimizes contact with the skin and prevents the
   incontinent episodes using a quality      damage occuring
   cleanser                                • Over use of soap can reduce the skin’s natural
• Use of skin barrier products               protective barriers. Cleansing of the skin in a
                                                    person with frequent incontinent episodes is best
                                                    using a product specifically for this purpose.
Best possible odour control                     •   the odour of faecal incontinence is one of the
• well fitting continence products, of              factors that makes it such a difficult health issue
                                                    to live with
   sufficient volume to contain loss            •   odour is minimized if it is contained and
• changing continence products/clothing             “sealed” around the body by well fitting
   as quickly as possible after an                  garments and continence products and not loose
   incontinent episode                              and open to the air
• use of a quality odour control product        •   odour is also minimized if the person is changed
                                                    as soon as possible
   for personal use and in the environment      •   use of a product to appropriately cleanse and
                                                    deodorize the skin and bedding as well as the air
                                                    will help reduce odour

Step 7:                Monitor/Evaluate strategies so far and if not improved……...

•   Refer to specialist practitioner/service    •   Specialist assessment and investigation may be
                                                    required. Specialist treatments will be based on
    • Gastro-enterology/ Colo-rectal
                                                    these findings and may include:
       medical specialist (referral via the         • Pelvic floor rehabilitation
       GP or other primary medical                  • Biofeedback and electrical stimulation of
       practitioner)                                    the pelvic-floor and anal sphincter
    • Continence Service                            • Use of anal plugs as a continence device
                                                    • Surgery
•   Brocklehurst, J., Dickinson, E., Windsor, J., 1999, “Laxatives and faecal incontinence in long-term care”,
    Nursing Standard, 13(52):32-36
•   Demata, E.U., 1999, Faecal Incontience Part 1: Literature review, anatomy and physiology, factors affecting
    incontinence” World Council of Enterostomal Therapists Journal, 19(4): 6-11
•   Demata, E.U., 2000, Faecal Incontience Part 2: Assessment and medical and surgical management”, World
    Council of Enterostomal Therapists Journal, 20(1): 12-16
•   Demata, E.U., 2000, Faecal Incontience Part 3: Nursing management”, World Council of Enterostomal
    Therapists Journal, 20(2): 12-16
•   Hinrichs, M., Huseboe, J., 2001, “Research-based protocol: Management of Constipation” Journal of
    Gerontological Nursing, February: 17-28
•   Norton, C., 1996, “Faecal Incontinence in adults 1: prevalence and causes”, British Journal of Nursing,
•   Norton, C., 1997, “Faecal Incontinence in adults 2: treatment and management”, British Journal of Nursing,
•   Talley, N.J. & Martin, C.J., 1996, Clinical Gastroenterology: A practical problem-based approach, Maclennan &
    Petty:Sydney (held in BHS library)
•   RDNS (Melbourne), 2001, A Care Model for Management of Faecal Incontinence for Clients Receiving Care in
    their home, Final Report for National Continence Management Strategy, Innovative Grant

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