When to ask for rectal tube?

[mandypants08]

Hello, so I'm a pretty new RN I graduated about a year ago then worked in the ED for about 8 months. I left a few months ago because I wanted to move into critical care my goal was get a job in the IMC and transfer to ICU eventually when I felt competent in critical care. So I got hired in the IMC and start soon, anyway onto the question.

I didn't deal much with poop in the ED for obvious reasons mostly b/c you have the pt for 2-3 hours. I also didn't deal with much poop in nursing school b/c we were able to choose our pt's, so it baffled me when classmates chose incontinent people, I didn't do that.

I hear so much about nurses and techs just swimming in poop all day on "the floors" but it also sounds like rectal tubes are pretty rare. Why is this? If someone is having even one loose stool an hour that seems like an indication for one...right? This isn't laziness talking imagine how uncomfortable it is to POOP on yourself and have to lay in it not to mention skin break down. Also the resources it takes to keep changing someone, staff, linens, time, etc. just seems impractical. And when I say lay in it I mean b/c it's not like you can be there the instant someone poops you might be in another room doing something for 20 mins.

So why aren't rectal tubes more common? And nurses when do you draw the line and ask an MD for a rectal tube?

[87RN]

We use rectal tubes occasionally in our ICU, usually for someone who already has skin breakdown and the stool has to be really liquid, no chunks or the tube would get clogged, and they have been having continuous loose stools for over 24 hrs . The patients that have one are usually unconscious. Our doctors don't like to write orders for them and we basically have to convince them how bad the skin is getting before they agree. Some of the reasons not to get one would be if they have recently had any rectal surgery, a tumor, large hemorrhoids, are on anticoagulants, risk of perforation/ ulcer/ necrosis, neuro conditions affecting sphincter control i.e. spinal cord injury ( also potentially causing autonomic dysreflexia) if the patient is confused, you risk them pulling it out. If they are starting feedings, the stool will likely start forming. Also, they aren't perfect, they often leak and need adjustments. Sometimes we use a rectal bag that we secure with an adhesive like an ostomy bag, those work pretty well and have less potential risks. My philosophy is that the less tubes/ invasive equipment the better for the patient. When you have a patient that is having frequent incontinent stools, try to find the cause, make sure MD is aware because they could change/ add medications,diet, order barrier creams, etc. If they are having that much diarrhea, you should also be thinking about dehydration and electrolytes. Be as prepared as possible. Get all your stuff ready and have extras of everything, put enough chucks down, and double glove. I try to have everything at the bedside, remove all the pillows and linens, I roll up my pad/ chucks so by the time someone comes to help it makes it a lot quicker. Make sure to use a barrier cream to minimize skin breakdown. Sometimes we use the suction catheter with just the tubing if its really bad, just make sure you change it right after!

I can't believe I wrote so much about rectal tubes, lol.

[DisneyNurseGal, BSN, RN]

Rectal Tubes are famously leaky. Only once in a blue moon does one seal 100% and catch everything. Also if the consistency changes, it can get clogged and the patient could retain, causing them discomfort. Couple times I have D/C a tube only to have the patient have a major blowout immediately after. One doctor explained to me that the pros don't always outweigh the cons with tubes. Nothing like an old fashioned cleaning and barrier cream! If you have someone with diarrhea barrier cream with last until their next brief change. I have never asked for a tube, and I usually inherit them when the patient gets transferred from the ICU

Also, I am glad I had the incontinent patients as a nursing student, because now that I do not have the choice, I can change a brief in 2 minutes flat, in the dark, by myself. Practice, practice, practice.

[RNsRWe, ASN, RN]

" I also didn't deal with much poop in nursing school b/c we were able to choose our pt's, so it baffled me when classmates chose incontinent people...." ~mandypants

Ok, off topic, but I just had to ask about this one: you CHOSE your patients, and therefore could choose what cares you could expect to provide? Wow. I think our instructors took special care to make SURE we got incontinent, demented, tube and bandage-laden patients!

[lwhatley]

Asking for a rectal tube is a last resort for me...it's for when I absolutely can't keep up with the amount of loose stool the patient is passing...there's a couple of reasons why this is the case for me personally...

1. In my mind, I've usually got tubes coming out of pretty much every body part in my patient, and I've got all of these sources of both discomfort, trauma, and possible infection....if I can limit even just one of those tubes going in, I'm going to do it; especially if we're talking the back door...

2. I always kind of resent the nurses that hop on the rectal tube train as soon as they see some loose stool. Loose stool happens in the ICU, especially given the scenarios a lot of these patients are coming from...post-op, tube-feeding, bowel program...get enough tube feeding and milk of mag in anyone and they're bound to be a poop fountain for a bit...you have to prepare to do a little doodoo control after the fact...warm up the barrier cream before hand, stack some chucks, run some warm soapy water and prepare for a few hours of twistin, turnin, scrubbin' and protecting....it's our job.

The time that I believe a rectal tube is necessary is in the cases where break down is actively occurring...because I definitely understand contact dermatitis happens after a significant amount of time left warm and wet down there...I also believe in the use of a rectal tube when the output is putting central lines and/or wounds at risk. I wouldn't smear fecal matter in a cut anywhere on my body, so I'm gonna try to protect wounds and lines as best as I can...and in this case, it's likely the rectal tube is better safe than sorry...

With that being said, like I said, I delay as long as I possibly can, and if I do put one in, I make sure I only keep it in for as short as possible...I attempt to find literally any other alternative measure I can....to be at the very least a little less emotionally traumatic for the patient.

[ChipNurse]

I work in an ICU where it seems every patient has loose stools. With that being said, I have only asked for a rectal tube one time in the past year and that was only because the patient was having a large amount of liquid stool every hour and his bottom was so raw that I thought it was best for his skin. I personally hate the tubes as they always seem to leak anyways, so it really doesn't save any time. In fact, i think some nurses assume the patient is clean with the tube in and does not inspect for leakage, so the stool sits around the tube for hours at a time, which just irritates the skin more. I am an advocate of good old fashioned peri care when the patient is incontinent. If the patient is frequently incontinent, I make sure to check every so often and get the patient cleaned up right away. I use a lot of barrier cream to protect the skin. To me it doesn't seem like any more work.

[Loo17]

Our facility states that rectal tubes are to be used as a last resort reserved for those with skin breakdown and only for a short period of time s/t increased risk of a pressure wound developing from the balloon. Plus the patient needs to be placed on a bunch of bowel meds to ensure the stool remains liquid as to not clog the tube. I have never seen someone develop a pressure wound in their rectum from a rectal tube but I assume it is possible with a 30ml balloon sitting there on a pressure point.

Here is a link to one type of rectal tube, seems like there are several contraindications and potential complications.

http://nursing.uchc.edu/unit_manuals/intensive_care/docs/FMS%2520Guidelines.pdf

[wooh, BSN, RN]

This isn't laziness talking imagine how uncomfortable it is to POOP on yourself and have to lay in it not to mention skin break down.

Just imagine how uncomfortable it is to have a tube and balloon up your butt.

I think you're now finally going to get to deal with all the poop you've been avoiding.

[Do-over, ASN, RN]

It is almost unbelievable how exciting it is to find that the rectal tube DID NOT LEAK ONE BIT in the two hours between turns.

I think they can help in some situations, but it is also an art and a science to position the system and the patient so that the tube drains and doesn't leak. Not to mention the large bag-o-poo hanging off the bed.

Sorry - edited to add, and its maybe off topic, but I sometimes wonder how people manage to clean themselves up after having a BM...

[Do-over, ASN, RN]

I think you're now finally going to get to deal with all the poop you've been avoiding.

Poo happens.

[mandypants08]

Thanks for all the responses, it was very helpful, all the posts mentioned things I didn't think about. Especially 87RN you mentioned many things I didn't consider. RNsRWe to answer your question more specifically we were assigned a block of rooms and were able to choose from that, we only got that luxury about mid way through the program, in the beginning we were assigned patients. Anyway thanks again everyone for taking time to answer my questions, much appreciated!