Fecal impaction removal

Definition

Fecal impaction removal is the digital (using the finger) means of breaking up and removing a fecal impaction, or mass of hardened, clay-like stool lodged in the rectum.

Purpose

Fecal impaction is the result of extreme constipation. As the patient is unable to expel the stool, it further accumulates into a larger, harder mass that is impossible to pass by normal defecation. This accumulated stool can extend up into the sigmoid colon, the loop of large bowel above the rectum. Impaction is most common in inactive elderly people, but there are other causes beside inactivity. Among the other causes are:

• medications, including antacids that have aluminum as an ingredient; calcium and iron supplements; a category of anti-hypertensive drugs known as calcium channel blockers; allergy medicines (antihistamines ); such psychotropic medications as antidepressants and tranquilizers; such hormones as estrogen and progestin; and medications to reduce spasms such as those used in treating Parkinson's disease
• poor bowel habits; not having a regular schedule for evacuating the bowel
• inadequate fluid intake
• a diet that is lacking in such fibers as bran, fruit, and vegetables
• such rectal disorders as rectocele

In addition to the discomfort this condition creates, untreated fecal impaction can also become a serious health problem, producing a chronically over-dilated bowel, or megacolon, that can require surgical correction. It is possible for rectal tissue to become damaged, ulcerated, or even necrotic (lose its blood supply due to the pressure of the stool). The most serious potential complication is that the lower bowel can become completely obstructed. Such intestinal obstruction is potentially fatal.

The possibility that the patient has a fecal impaction should be considered if he or she shows any or all of the following symptoms:

• complaints of inability to have a bowel movement despite frequently feeling the urge to defecate
• upon defecation, the stool appears to be either diarrheic or thin and pencil-like
• abdominal pain
• bloating and a swollen or hard abdomen
• anorexia, or lack of appetite; nausea; and vomiting
• complaints of general malaise, or not feeling well
• the presence of hard stool in the rectum
• increased restlessness in patients suffering from Alzheimer's disease or other forms of dementia

Precautions

This digital breaking up and removal of impacted stool can potentially damage the mucous membrane linings in the bowel, and the stimulation to the vagus nerve that has endings in the rectum can cause heart irregularities. It is therefore a procedure that is undertaken only with extreme caution. Most often, nurses remove fecal impactions upon receiving a physician's order, or under a physician's supervision.

Description

As gently as possible, the nurse inserts a gloved, lubricated index finger and massages around the edges of the impaction, gradually working the gloved finger into the mass to break it up. The broken-up pieces of stool are dislodged by carefully working them downward toward the end of the rectum. During this procedure, the patient should be checked regularly to assure that there are no untoward effects such as weakness, diaphoresis or clamminess, or changes in pulse rate.

Preparation

The nurse positions the patient on his or her side, with knees flexed and back toward the nurse. A waterproof pad is placed under the patient's buttocks, and a bedpan to hold any removed stool is kept nearby. Occasionally, a patient will request to stand in the bathroom near the toilet during this procedure, but that is not advisable due to possible adverse reactions and the fact that this can be an exhausting process. The nurse then puts on rubber gloves and applies lubricant to the index finger that will be inserted to break up the impaction. Explanation of what is to be done, and reassurance that if the procedure is causing discomfort it will be stopped immediately, should be given before beginning.

Aftercare

After the disimpaction is completed, it may be necessary to administer an enema or give a suppository to complete the stool removal. The most important aspect of care is the prevention of the reoccurrence of problems with elimination.

Complications

Vagus nerve stimulation, causing cardiac irregularities with possible fainting or weakness, is the most serious potential complication. However, rectal bleeding, the result of trauma to the bowel mucosa, can also occur.

Results

Expected results will be the removal of the hardened stool from the patient's rectum, making the patient much more comfortable.

KEY TERMS

Megacolon —A massively swollen colon, usually associated with severe and chronic constipation that can exist as a congenital condition or develop later in life.

Sigmoid colon —The S-shaped part of the colon, part of the large intestine, positioned between the descending colon and the rectum.

Vagus nerve —The tenth and longest cranial nerve, responsible for control of the heart and other internal organs.

Health care team roles

This procedure is rarely undertaken, as normally health care staff try to prevent the occurrence of fecal impaction through medications, diet, and such treatment as enemas or suppositories. Such prevention is desirable due to the risks involved. However, if fecal impaction removal must be done, it should be done only by a physician or nurse, as they should be aware of the possible untoward effects.

• A nurse will normally be the person who actually removes impacted stool.
• Both registered nurses (RNs), or licensed practical nurses (LPNs) must complete a prescribed course in nursing and pass a state examination. RNs typically have a degree in nursing. If the physician does not disimpact the patient, usually it will be the job of a RN. However, in some situations, a LPN may be the person responsible for carrying out this procedure.

Resources

BOOKS

Kozier, Barbara, RN, MN, Erb, Glenora, RN, BSN, Blais, Kathleen, RN, EdD, Wilkinson, Judith M., RNC, MA, MS. Fundamentals of Nursing, Concepts, Process and Practice, 5th ed. Redwood City, CA: Addison-Wesley, 1995.

OTHER

"Fecal Impaction." Medline, U.S. Department of Health and Human Services, National Institutes of Health. <http://www.nlm.nih.gov/medlingplus>. July 20, 1999.

Toth, Peter P., MD, PhD. "Gastroenterology: Constipation and Fecal Impaction." University of Iowa Family Practice, Virtual Hospital. Feb.12, 2001.

Joan M. Schonbeck