Nursing diagnosis: Bowel Incontinence/Constipation related to Disruption of innervations to bowel and rectum, Perceptual impairment, Altered dietary and fluid intake, Change in activity level Medications
Possibly evidenced by
Loss of ability to evacuate bowel voluntarily
Gastric dilation, ileus
Desired Outcomes/Evaluation Criteria—Client Will
Verbalize behaviors and techniques for individual bowel program.
Reestablish satisfactory bowel elimination pattern.
Nursing intervention with rationale:
1. Auscultate bowel sounds, noting location and characteristics.
Rationale: Bowel sounds may be absent during spinal shock phase. High tinkling sounds may indicate presence of ileus.
2. Observe for abdominal distention if bowel sounds are decreased or absent.
Rationale: Impaired innervation causes paralysis of the bowel (ileus) and bowel distention. Note: Overdistention of the bowel is a trigger for AD, once spinal shock subsides. (Refer to ND: risk for Autonomic Dysreflexia.)
3. Note reports of nausea and onset of vomiting. Check vomitus or gastric secretions (if tube in place) and stools for occult blood.
Rationale: Gastrointestinal (GI) bleeding may occur in response to injury (Curling’s ulcer) or as a side effect of certain therapies— steroids or anticoagulants.
4. Record frequency, characteristics, and amount of stool.
Rationale: Assessment of bowel movement helps identify degree of impairment or dysfunction and required level of assistance.
5. Recognize signs of fecal impaction—no formed stool for several days, semiliquid stool, restlessness, increased feelings of fullness in or distention of abdomen, presence of nausea, vomiting, and possibly urinary retention.
Rationale: Early intervention is necessary to effectively treat constipation or retained stool and reduce risk of further complications.
6. Establish regular daily bowel program—digital stimulation, prune juice and warm beverage, and use of stool softeners or suppositories at set intervals. Determine a routine of bowel evacuation.
Rationale: A lifelong routine bowel program is necessary to control bowel evacuation. Bowel program is important to the client’s physical independence and social acceptance. Note: Bowel movements in clients with upper motor neuron damage are generally regulated with suppositories or digital stimulation. Lower motor neurogenic bowel is more difficult to regulate and usually requires manual disimpaction. Incorporating elements of client’s usual routine may enhance cooperation and success of program. Note: Many clients prefer morning program rather than evening schedule often practiced in acute and rehabilitation setting.
7. Encourage well-balanced diet that includes bulk and roughage and increased fluid intake at least 1,500 to 2,000 mL/day, including fruit juices.
Rationale: High fiber and fluid intake improve consistency of stool for transit through the bowel. Note: Over-the-counter (OTC) fiber products and cereals, prune juice, applesauce, and bran often provide adequate fiber for effective bowel management.
8. Observe for incontinence and help client relate incontinence to change in diet or routine.
Rationale: Client can eventually achieve normal routine bowel habits, which enhance independence, self-esteem, and socialization.
9. Restrict intake of caffeinated beverages, such as coffee, tea, colas or energy drinks, if indicated.
Rationale: Diuretic effect of caffeine can reduce fluid available in the bowel, thus increasing the risk of dry, hard-formed stool.
10. Provide meticulous skin care.
Rationale: Loss of sphincter control and innervation in the area potentiates risk of skin irritation and breakdown.