NURSING PATIENT CARE POLICY & PROCEDURE
Nursing Manual (Red)
Policy #: 2.23A
Title: Use of Fecal Management System
To effectively divert and contain liquid and semi-liquid stool away from the body of
adult patients with large amounts of incontinent liquid stool using an internal fecal
A. Fecal Management System Kit (Central Service (CS) Item Number 4008206)
(such as DigniShield®) – Kit contains system, 1 bag, 60 mL luer-lock syringe,
water soluble lubricant, odor eliminator
C. Extra fecal management bags (CS Item Number 4008207)
D. Slip-tip syringe (CS Item Number 1219989) for stool sampling
A. Provider order is required for the insertion of the internal fecal management
B. Consider use of an external fecal incontinence collector (CS Item Number
2202083) as a first line device for fecal incontinence and for patients who have
contraindications for insertion of an internal fecal management system.
C. The internal fecal management system shall only be used on adult patients
experiencing liquid or semi-liquid fecal incontinence greater than 3 occurrences in
24 hours (or more than 250 mL daily), or who have met any of the following
1. Positive for clostridium difficile
2. External fecal pouch was unsuccessful
3. Receiving ongoing oral Lactulose therapy
D. Contraindications for the insertion of an internal fecal management system:
1. Pediatric patients (may be appropriate for adult-sized adolescents)
2. Suspected or confirmed rectal mucosa impairment (i.e., severe proctitis,
ischemic proctitis, mucosal lacerations)
3. Large bowel or rectal surgery within the last year
4. History of ileo-anal anastomosis or internal rectal pouch (e.g., S or J
pouch) – discuss with physician
5. Rectal or anal injury
6. Current fecal impaction
7. Hemorrhoids of significant size and/or symptoms
8. Rectal or anal stricture or stenosis
Page 2 of 5
9. Suspected or confirmed rectal/anal tumor
10. Loss of rectal tone
11. Any in-dwelling rectal or anal device (e.g., thermometer) or delivery
mechanism (e.g., suppositories or enemas) in place.
12. Sensitivity or allergies to any of the product components.
13. Consult Wound and Skin CNS with additional questions regarding
potential patient contraindications.
E. The device is not intended for use beyond 29 consecutive days. When continuous
use approaches this length of time, discuss with medical team plan for removal
and/or removal followed by insertion of new internal fecal management system.
F. Liquid medications that have been ordered for administration per the rectal route
may be administered through the fecal management system. Refer to UWHC
Administrative Policy 8.17 Administration of Medications and section V. F of this
IV. PRECAUTIONS AND OBSERVATIONS
A. Use with caution in patients with the following conditions: neutropenia, toxic
megacolon, irritable bowel disorders, radiation patients, patients receiving
anticoagulant and/or anti-platelet therapy. If signs of rectal bleeding occur,
remove the device immediately and notify a physician.
B. Notify a physician immediately if any of the following occur:
1. Rectal pain
2. Rectal bleeding
3. Abdominal symptoms such as distention/pain
C. Solid or soft-formed stool cannot pass through the catheter and will obstruct the
opening. The use of the device is not indicated for solid or soft-formed stool. If
the patient's bowel control, consistency and frequency of stool begin to return to
normal, discontinue use of the device.
D. Standard precautions will be followed according to Hospital Administrative
policy 13.07, Standard Precautions & Transmission-based Precautions (Isolation)
and hand hygiene will be followed according to Hospital Administrative policy
13.08, Hand Hygiene.
A. General Guidelines
1. The device may be removed as needed to perform a digital rectal
examination and then be replaced.
B. Directions for Use:
1. Obtain provider order for insertion.
2. Explain rationale and procedure for the device to patient/family.
3. Patient may feel some pressure with insertion.
4. Perform hand hygiene and don clean gloves.
5. Perform a digital rectal examination to check for adequate rectal sphincter
tone and evaluate for fecal impaction. If sphincter tone is adequate and
fecal impaction not present, proceed with insertion steps.
6. Prepare fecal management system prior to insertion. If air remains, attach
the provided 60 mL syringe to the green inflation port and withdraw air.
Page 3 of 5
a. Verify the retention cuff has been completely deflated by
squeezing the cuff.
b. Fill the empty syringe with 45 mL tap water or normal saline and
attach to the green inflation port. Do not over fill beyond 45 mL.
c. Attach collection bag to the connector at the end of the catheter.
Pull back on the green trigger switch and engage the piston valve
onto the collection bag hub. NOTE: the green ring at the base of
the collection bag will NOT be visible when the piston valve is
7. Position an incontinent pad under patient, and position patient in the left
side-lying position; if unable to tolerate, position patient so access to the
rectum is possible.
8. Fold retention cuff (see link:
a. Hold left point of the cuff between the thumb and index finger.
b. Fold the top right point of the cuff down and to the left in a 45
degree angle, in order to create a conical shape with a leading edge
for ease in insertion.
9. Generously coat the patient’s anus with lubricating jelly. Lubrication may
also be applied to the cuff.
10. Hold the folded cuff between your thumb and index finger. Gently insert
the cuff end through the anal sphincter until the cuff is beyond the external
orifice and well inside the rectal vault.
11. Inflate the balloon with 45 mL of water or saline by slowly depressing the
syringe plunger. Under no circumstances should the balloon be inflated
more than 45 mL.
a. The inflation port has an external pilot balloon used as a guide to
determine proper inflation; as the cuff inflates, the pilot balloon
also inflates. The pilot balloon should be used as a reference to
determine proper cuff inflation. Note: Ensure that the inflation port
remains parallel to the catheter in order to prevent kinking of the
inflation lumen and blockage of injected fluid.
12. Remove the syringe from the inflation port, and gently pull on the catheter
to check that the balloon is securely in the rectum and that it is positioned
against the rectal floor.
13. Position the length of the drainage tubing along the patient's leg, avoiding
kinks and obstruction. (Take note of the position indicator line relative to
the patient's anus. Regularly observe changes in the location of the
position indicator line as a means to determine movement of the retention
balloon in the patient's rectum. This may indicate the need for the balloon
or device to be re-positioned.)
14. Hang the bag by the hanger on the bedside at a position lower than that of
15. Document insertion in the LDA section of Health Link.
C. Irrigation of the Retention Cuff and Drainage Tubing
1. Flush the catheter as needed if the tube is not draining or the tubing
a. The rectal vault: Flush 60 to no more that 240 mL of sterile water
through the clear port labeled “irrigation” to maintain an
unobstructed flow of stool into the collection bag.
Page 4 of 5
b. If water leaks around tube, consider repositioning.
c. The drainage tubing: Flush sterile water through the purple “flush”
port to clear tube of thick stool.
2. If repeated flushing with sterile water does not restart the flow of stool
through the catheter, the device should be inspected to ascertain that there
is not external obstruction (i.e. pressure from a body part, piece of
equipment, or resolution of diarrhea). If no source or obstruction of the
device is detected, use of the device should be discontinued.
D. Stool Sampling
1. Uncap the white sample port.
2. Gently kink the catheter segment just past the sample port and tilt or milk
the catheter to collect fecal matter around the sample port.
3. Insert a slip-tip syringe into the sample port valve and draw the
appropriate sample of fecal matter into the syringe.
4. Withdraw syringe and secure the white cap back onto the sample port.
5. Label patient specimen at bedside according to Clinical Laboratories
Policy 1502.5.06, Acceptance Policy for Specimen Identification.
E. Patient Monitoring and Maintenance of Device
1. Measure output every shift and as needed by placing mark on drainage bag
with date and time and document. Subtract any irrigation used.
2. Observe the device every shift and as needed for obstructions from kinks,
solid fecal particles, leakage or external pressure. Flush as needed if
device is blocked.
3. Small amounts of moisture or seepage around the catheter is anticipated
while the device is in place. Initiate perirectal skin protection using the
appropriate barrier cream according to the "Urinary and Fecal
Incontinence Associated Dermatitis Prevention" guideline (see Related
a. Consider repositioning and re-seating the balloon.
b. Consider placing a drain sponge around tubing at rectum to absorb
4. Change the collection bag as needed.
a. Grab the piston connector, pull back on the switch until the piston
ejects from the collection bag.
b. Once the bag is removed, insert the bag plug into the collection
bag hub and dispose in a red biohazard waste container.
c. To replace the collection bag, refer to ‘attach collection bag’
F. Rectal Medication Administration
1. Position the patient in a side-lying position.
2. Attach a Luer lock syringe to the clear irrigation (“IRRIG”) and flush the
system with sterile water.
3. Attach a Luer lock syringe with prescribed medication to clear irrigation
(“IRRIG”) port, elevate the drainage tubing to facilitate medication
retention, and infuse the prescribed amount of medication.
4. Flush the irrigation line with at least 10 mL of sterile water to ensure
delivery of medication into the rectum.
5. Slide the red tube clamp onto the drainage tube and clamp the tube for the
prescribed dwell time, positioning the clamp close to the patient’s buttocks
without the clamp touching the patient’s skin.
Page 5 of 5
6. At completion of prescribed dwell time, remove the red clamp and verify
unobstructed flow from the patient into the collection bag. Attach the tube
clamp to the piston valve hanger string on the collection bag for storage.
G. Removal of the Device
1. Attach 60 mL Luer lock syringe to the green inflation port and slowly
withdraw all the water from the retention balloon.
2. Grasp the catheter as close to the patient as possible and slowly slide it out
of the anus.
3. Dispose of the device in a red biohazard waste container.
4. Complete LDA documentation in patient’s clinical record.
VI. UWHC CROSS REFERENCES
A. UWHC Administrative Policy 8.17, Administration of Medications
B. UWHC Administrative Policy 13.07, Standard Precautions & Transmission-based
Precautions (Isolation) for Inpatient Settings
C. UWHC Administrative Policy 13.08, Hand Hygiene
D. Clinical Laboratories Departmental Policy 1502.5.06, Acceptance Policy for
E. Urinary and Fecal Incontinence Associated Dermatitis Prevention Guideline
A. C. R. Bard, Inc. (2014 ) DigniShield stool management system product insert.
B. Marchetti, F., Corallo, J. P. Jr., Ritter, J., & Sands, L. R. (2011). Retention cuff
pressure study of 3 indwelling stool management systems: randomized study of
10 healthy subjects. J Wound Ostomy Continence Nurs, 38(5), 569-573.
C. Pittman, J., Beeson, T., Terry, C., Kessler, W., Kirk, L. (2012) Methods of
Bowel Management in Critical Care. JWOCN, 39(6), 633- 645
D. Wound Ostomy Continence Nursing (WOCN) Society (2013) A quick reference
guide for managing fecal incontinence. Mt Laurel, NJ
E. C.R. Bard, Inc. (2014). DigniShield Administration of Medication.
VIII. REVIEWED BY
Clinical Nurse Specialist, Trauma Life Support Center
Clinical Nurse Specialist, Wound and Skin
Nursing Patient Care Policy and Procedure Committee, February 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer