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 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
ZippyGBR said:
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 .

I think this hits the nail firmly on the head, and auditors and the people who check quality measures have taken (rightly so, in most cases) to seeing impaction as a sign of poor care. Facilities may try to forbid manual removal of stool, or at least insist that it not be done without a doctor's order, so that no 'red flags' are raised. It's not really that manual removal is highly dangerous (in most cases), it's that facilities are thinking 'well if we don't allow it, maybe we won't get into trouble for not addressing constipation properly'. In my opinion, facilities would be better off ensuring that all staff have ongoing training in bowel management and prevention of constipation, like Leslie said it (bowel management) is something that some nurses don't take seriously enough.

Agree with everyone who has said this is the absolute last resort and should not be done unless there is no other choice, but that doesn't change the fact that it is still necessary on occasions.

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Realize this post is quite old but I'm alarmed at the lack of knowledge. Digital removal of an impaction should be gently and carefully done. The risks of a digital removal of a fecal impaction are the same as an enema. Perforations, vasovagal responses, bleeding are common to both procedures. Can understand wanting a doctor's order but even that seems demeaning. We are taught critical thinking skills in school but I don't see many nurses using them. If a nurse is comfortable giving an enema, placing a ng tube, inserting a foley she should be taught and be comfortable removing a fecal impaction.

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Specializes in Critical Care.

Back in the day (way back) this was standard practice when I was an STNA in LTC. However, I have been an RN for 10 years in hospitals. We are NOT allowed to do this r/t to risk of bowel perforation and only a physician can do this...order or not (just remember a doctor's order will not mean JS if you find yourself in front of the BON). But then again, depends on where you work.

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Specializes in Hospice / Psych / RNAC.

I faced the same set of circumstances when I first worked in a LTC. I was told the exact thing...finish it. The elderly man was sitting on the toilet waiting for his manual disimpaction. He told me he use to do it himself but no longer could.

Then I investigated and found I needed a doc's order. You must know the history of the person. In many cases in LTC with the elderly many of them have been removing their stool themselves for years. I have come across many elderly people when questioned point blank will admit to it. I just ask them to please use gloves (:speechless:).

The down and dirty of the bowel habits of people who are pre-dementia, dementia, memory impaired, etc... and questions you are afraid to ask because you may get a truthful answer.

The poster is not a troll; you people are not realizing that nursing is about all aspects of human behavior. The states can go ahead and OUTLAW the practice of manual disimpaction but it won't stop people from doing it themselves, thus later on opening themselves up to further problems...

Save for paras, quads and the like; many people assist themselves in that area. Then once institutionalized they need assistance. The rectum is very flexible and you must know what you're doing (vagal responce, heart patients/residents, etc...). Enemas are your best bet for people who don't usually help themselves so don't start (also solving the why). The bowel can be trained at any age if you know what you're doing and you have a willing patient with a healthy bowel.

And there's the trick; by the time someone is old enough to be institutionalized it's almost too late. Doesn't make the problem go away. We need individualized solutions. This is an area where a one solution for all does not work. I am not advocating manual disimpaction; simply stating that there is a need at times.

If this person was bleeding I wouldn't have touched him but called his doc. It could be hemorrhoids, etc..., the possibilities are endless. It could also be an aggressive nurse who doesn't know what they're doing. Many on here almost seemed in disbelief at the idea of manual disimpaction and think it can go away with a policy...welcome to the real world. "There's the rub" :up:

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According to Perry, Potter and Ostendorf (2018), a doctor's order must be obtained prior to performing digital disimpaction: "Obtain written order before performing procedure because this procedure involves excessive stimulation of vagus nerve" (p. 913). Also, "because of the potential to stimulate the sacral branch of the vagus nerve, patients with a history of dysrhythmias or heart disease have a greater risk for changes in heart rhythm. Monitor patient's pulse before and during procedure. This procedure is often contraindicated in cardiac patients; if in doubt, verify with the health care provider" (Perry et al., p. 913). One of the unexpected outcomes is if the "patient experiences trauma to rectal mucosa as evidenced by rectal bleeding" (Perry et al., p. 914). If this occurs, digital disimpaction must be stopped immediately and the health care provider notified (Perry et al., p. 914).

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical Nursing Skills & Techniques, 9th ed. St. Louis, MO: Elsevier.

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This is NOT about you. Your resident should not have to go through disimpaction. Institute a daily bowel program.

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Specializes in ICU Registered Nurse.

There are various reasons and also some disease conditions causing constipation and most of them can be resolved by taking laxatives. In cases of severe constipation, digital removal is ordered by the physician. The fecal disimpaction is commonly performed in emergency ward. Though performed commonly, we should not neglect the risks of this procedure. 

Before performing the procedure health personnel must verify if the patient is using any anticoagulants or has any disease condition that ulters there bleeding profile and also the presence of hemorroids and its grade.

The major risk of digital rectal disimpaction are:

1. Injury to the small blood vessels of rectum (which is in the case you mentioned in the article): It is very common to rupture blood vessel during the procedure. After the disimpaction, doctor orders sitz bath and ointment to promote healing and prevent the infection.  But if the bleeding is severe continuing the disimpaction is not indicated.

2. Rectal perforation and Rectal fissures

3. Dilated rectum

4. Vagal stimulation: This one is the serious one because there can be vagus nerve stimulation and the patient can go to severe bradycardia and can lead to death.

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