Fecal Disimpaction

Fecal impaction is a potentially fatal condition of the bowel. In this article, we’ll provide an overview of fecal impaction and subsequently, digital fecal disimpaction, within the context of the nursing scope.

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Fecal Disimpaction

Fecal Impaction Overview

Fecal impaction occurs when dried and hardened feces cause severe constipation.

Impaction can occur at any level of the intestines—rectal, sigmoid, descending, transverse, or ascending colon. The most common area is the lower level such as the sigmoid and rectum.

Table of Contents

Causes and Risk Factors

 The condition is most prevalent amongst the elderly; in a review of existing clinical research, 45% of patients were older than 65. 

Common risk factors for stool impaction are1:

  • Chronic constipation, CC (50%)
  • Neuropsychiatric disease (27%)
  • Gastrointestinal tract damage from prior surgery or pre-existing medical conditions (12%)

Additionally, patients at greater risk for impaction are those with (not exhaustive)2:

  • A sedentary lifestyle
  • Usage of anticholinergics, such as amitriptyline, atropine, antihistamines
  • Brain or nervous system conditions
  • Frequent usage of laxatives and medicines used to treat diarrhea
  • Frequent narcotic usage
  • Generally poor diet or hydration
  • Barium enemas
  • Enlarged prostate
  • Irritable bowel disease (IBS)
  • Inflammatory Bowel Disease (IBD)
  • Hypothyroidism

What is Digital Fecal Disimpaction?

Spontaneous bowel movement becomes impossible for patients with severe impaction, and they will require help to evacuate, or disimpact, their bowels.

Fecal disimpaction can be done by a healthcare provider or caregiver using their fingers to manually remove the feces from the rectum, called manual disimpaction. Lubrication and gloves must be used and care given in regard to the pain level of the patient. 

The patient is already very uncomfortable, and performing the digital disimpaction may exacerbate the pain. Enemas can help soften the stool and make the stool easier to remove.

Digital disimpaction may also be called:

  • manual evacuation, 
  • digital removal of feces, 
  • or digital evacuation

Can a Nurse Perform a Digital Disimpaction?

It is within the nursing scope to disimpact patients.3,4 However, whether a nurse is authorized to perform this procedure will depend on their level of training, the policies and procedures of the healthcare facility they work in, and the laws and regulations of the jurisdiction they practice in.

Disimpaction is a medical procedure that requires experiential training and is often performed by a physician or a specially trained nurse under the direction of a physician. It is potentially preferable for the patient, when possible, for a gastroenterologist to perform the procedure as they can:

  • Sedate the patient for increased comfort
  • Use a colonoscope to examine the colon once the impaction is released to search for possible causes and any abnormalities

The GI doctor can also go further into the colon and then flush the fleets enema into the colon at a higher level using the colonoscope to help finish removing the stool. The fleets will soften and loosen the stool so that the patient can then evacuate their bowel with minimal effort. 

When is a Disimpaction Necessary?

The usual signs and symptoms of impaction are5:

  • Bloating of the abdomen
  • Feel the need to poop but being unable to
  • Loss of appetite and lethargy
  • Pain in the lower back or abdomen
  • Fecal incontinence and diarrhea
  • Nausea and vomiting
  • Rectal bleeding

Patients should have a conversation with their doctor as to whether their symptoms are constipation or fecal impaction. Nurses should report to the doctor promptly if they notice any of these symptoms in their patients.

A thorough review of the patient's history of bowel movements, signs, and symptoms, is essential.

Process for Disimpacting a Patient

Administration of an enema to help break up and soften the stool prior to disimpaction may be helpful5. Some physicians may prescribe a strong laxative such as a colon prep called polyethylene glycol6. The latter prep is used to clean out the colon prior to a colonoscopy. Many of these patients will not be able to tolerate such a prep due to the volume. They may also throw it back up since they have a blockage from the fecal mass. The most effective method of removing the stool is by physically removing it. 

Removing the stool manually requires gloves and lubrication, and if ordered by the doctor, rectal irrigation or suppositories can be used intermittently. Remember to be gentle because the patient will be uncomfortable.  The stool can be broken down into removal pieces. Depending on how much stool is present, it may take some time to remove, or it may take a couple of attempts. It is not uncommon to see rectal bleeding during the removal because the patient may have internal or external hemorrhoids. They may have rectal or sigmoid ulcers due to the stool being stationary up against the mucosa. Once the stool is removed, the patient will feel better right away. The bowel does not have pain fibers, but it has stretch fibers. So once the stretching of the area is released, the pain should subside. 

Patient Teachings and Prevention

The key to helping these patients is prevention. Educating them and their caregivers on how to avoid further impactions will decrease the risk of future reoccurrence.

Subsequent impactions can further damage the lower colon structures and the anal sphincter. If the anal sphincter is damaged, the patient can become incontinent. Rectal perforation or anal fissures can occur because the colon is already being stretched thin by the stool. Their hemorrhoids may worsen as well, or they can get an infection. 

The overuse of laxatives can lead to decreased muscle tone and peristalsis in the colon. Also, fecal impaction can cause increased pressure in the colon lumen and lead to stercoral ulcers and perforation1. Both of these can lead to a megacolon which is when the colon becomes boggy and without muscle tone and can sometimes require surgery. 

Fecal impaction happens more often in elderly women according to one study. 29% of those in the same study, died from secondary conditions of fecal impaction. 

The best way to mitigate your risk of impaction and recurrence of impaction are6:

  • Drinking enough fluids
  • Staying as active as your condition will allow
  • Increasing dietary fiber
  • Taking medications such as stool softeners as prescribed by their doctor

Anecdotal Clinical Experience

The easiest method of removing impacted stool is by bringing them to a gastroenterology unit and a GI doctor uses both manual removal and a colonoscope to remove impacted stool. The patient is sedated, and blood pressure, heart rate, and respiration are monitored. 

The physician can remove some fecal matter digitally, and then use the colonoscope to possibly go beyond the obstruction. 

Enemas can be flushed through the scope and into the colon from as high as the cecal area. This will assist in the complete removal of the stool.

The doctor will also be able to see the colon mucosa and document the damage by taking pictures. He can also take biopsies if areas of ischemia or colitis are noted from the blood flow being impeded by the hard stool lying up against the mucosa. 

STAFF NOTE: Original Community Post 

This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:

Quote

Hi, I'm a new grad nurse working at an assisted living facility. A nursing student reported that one of our residents had an impaction and after doing a digital extraction (without my consent) started bleeding. I informed my supervisor right away and told me to continue the extraction because this was "normal" for her. I went back and checked to see if the resident is still actively bleeding. There was still some bleeding going on but not as much as it was. I was hesitant to do the dis-impaction because of 3 main reasons:

  1. I never did it before and I am unsure of all the precautions to take when doing this procedure.
  2. I'm not sure if there are any special precautions needed for people actively bleeding. and
  3. I don't even think it's OK to digitally disimpact someone who is actively bleeding. I called my supervisor again for assistance but she just got mad and told me that I am not willing to learn new things.

Was wondering who is in the wrong in this situation, it's been bothering me all night last night and made me look at my supervisor a different way now.

Digital disimpaction can be done by nurses who have been instructed properly. Being a new grad, the supervisor should have instructed you on how to do it and what to watch for. There should be a policy that will tell you the way that your facility has approved of performing a digital disimpaction. 

When bleeding is present, then a doctor should be consulted to do an exam of the rectal and sigmoid area to make sure that the bleeding isn't a perforation. The doctor could also assist in further evacuating the stool. Bleeding is a sign of trauma, and close attention should be paid, which you did. You did the right thing by informing your supervisor and watching the bleeding. 

If you can, put a call to the doctor next time and tell him the situation, or catch him the next time he does rounds to get his recommendation. Document everything! Document that you informed your superior, the physician, the amount of bleeding, and any other findings.

References

  1. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-015-0162-5 
  2. https://medlineplus.gov/ency/article/000230.htm
  3. https://www.mountsinai.org/health-library/diseases-conditions/fecal-impaction
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053865/
  5. https://my.clevelandclinic.org/health/diseases/23085-fecal-impaction
  6. https://www.niddk.nih.gov/health-information/digestive-diseases/constipation
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Brenda F. Johnson

About Brenda F. Johnson, MSN

Gastrointestinal Columnist
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Manually removing fecal impactions is risky with too many potential problems that could arise. Best thing to do is call the physician & get an order for an oil retention enema (suppositories do not work on impactions) but if there was bleeding present I would have sent them in to the clinic or ER for an exam. Don't ever let any nurse tell you manually removing impactions is OK. Did you have a doctor's order to remove the impaction...thats another thing you could have told your supervisor if you didn't have an order. Don't let a supervisor bully you if you feel something is unsafe, you will learn to assert yourself the longer you are in nursing!

thanks,

Jerenemarie

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Specializes in Cardiovascular, ER.

I have only had to disimpact a couple of times, but one thing you should watch out for is if they have an extensive cardiac hx such as heart block, CHF, etc. Just keep your eye on their heart rate - I have had a pt vagal down pretty low and had to stop the disimpaction.

Like said above, I would definitely get an MD order to do this and since you haven't done it before or even if you have and feel uncomfortable, ask for help. You should not have to do stuff like this on your own the first time.

The nursing student disimpacted your patient on his/her own? That is not cool, I would speak up about that.

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Specializes in Developmental Disabilites,.

I was taught never to manually disimpact. The risk is too high. That student nurse and your supervisor were way out of line. You should discuss this with the student and the clinical instructor. As far as your supervisor goes she is just plain lazy!

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Does this vary by state? We are taught how to manual disimpact in first semster and as long as we have cleared it with our nurse and our instructor is present we can do one. We don't need a physicians order. It's concidered nursing judgement. I have never given one, but I have assisted in holding other students patients while they performed the disimpaction. This is the first I've heard nurses say that it shouldn't be done and it needs an order from the MD.

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I'm a bit taken aback to hear that some nurses are being taught that manual disimpaction is "too risky" or requires doctor's orders to perform. Although my experience is primarily in the spinal cord injury/damage population, I've always understood this to be a fairly standard practice and within the realm of the nurse's discretion.

Your supervisor exercised very poor judgment by insisting you perform a procedure that you've never done before on your own.

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The state of Minnesota looks at impactions as a BIG problem...one of the first questions they have is the patient dehydrated or not & what type of meds are they on to contribute to the problem (psychotropic meds which cause dry mouth, etc). I'm speaking from a Long Term Care point of view. If an MDS is submitted with "impaction" listed, that immediately raises a big flag for the survery team. Again, this is how impactions are looked at in the elderly population, I have no idea how acute care deals with it. Also manually removing an impaction is very uncomfortable for the elderly plus it can cause a vagal episode. I would hate to be a nurse disimpacting someone who "passes out cold" on me, especially if I didn't have a doctor's order!

thanks!

Jerenemarie

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Well, look folks. When did digital disimpaction turn into something that was beyond nursing's scope of practice. Some of the stuff that's been mentioned is certainly true, and besides, the procedure is not comfortable, stressless or soothing, and there are some risks... But, are we professionals or... do we throw up our hands and play pitiful? There is still this thing called the nursing process, yes?

OK... there is a chance for a vagal response when you stimulate the rectum. But being impacted and straining at stool can do the same thing.

Yes... disimpacting someone will traumatize some tissues... as will a big wad of dry stool the patient can't move.

Yes... you'd have to assess for rectal bleeding (and is the patient on anticoagulants? How bad are those hemorrhoids? There isn't any chance of increased portal pressure, right? You say the patient is bleeding? Is it a lot? If so, what are his coags? Blood in the linen should prompt some thinking and further assessment.)

Exactly how long ago was the last BM? What is his/her abdominal assessment? Are they eating? Are they drinking? Are they on anticholinergics or opiates? Do they get out of bed? Are they getting their stool softeners? What diet are they on? Is there something else we can do to help them because... this is at the absolute bottom of my to-do list.

Um... I've worked in 6 different states and it's been a nursing judgement. Yes, the MD is in the loop and if you need a second opinion, sure... talk to the MD first.

But come on folks.

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Specializes in CNA.

At our facility disimpactions require a Dr's order (LTC). To be honest Ive seen nurses do it w/o an order though. Not sure how they get by with it. I do not know why they require a dr order, in nursing school we were taught that it is a nursing judgement call as stated by other posters. Maybe its just a LTC thing??

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Specializes in Spinal Cord injuries, Emergency+EMS.

In someone with a 'normal' bowel reaching the point of requiring a manual evacuation indicates a failure somewhere along the line, it doesn't necessarily mean it's the'fault' of Nurses or Doctors - such as the patient who refuses stool softeners/ macrogol / stimulant laxatives...

in someone with a Neurogenic bowel due to Spinal cord injury or other neurological condition it's a routine and perfectly 'normal' option either in it's entirity or to 'finish off' after suppositories or a microenema .

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Manual disimpaction is within the nursing scope of practice, although some facilities do require a doctor's order. Also, starting with the less invasive alternative, such as an oil retention enema to soften the stool, is never really a bad idea unless the resident is so uncomfortable that more immediate intervention is necessary.

I think the student was wrong to perform this procedure without first checking with you, though.

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Specializes in m/s.

am i overthinking this? manual disimpaction= actual entry of object (gloved finger) to pt cavity and pulling out fecal matter, yes? had a pt , language barrier, took lots of kayexalate, made some stool, indicated done, helped to wipe and still saw significant dilation of cavity with matter present. gently pressed outer area and encouraged pt to bear down, got more matter out, but never had insertion of other (gloved) into pt. still manual disempaction or does that fall into other category? pt was on tele, never got a call about any issue, but kinda reviewing my day for what i did well, what i could do better, and what i could learn from. taking this opportunity to ask my colleages- your thoughts? thanks for your support! :)

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