Fleet enema = NO results!!

[kwagner_51]

Here is the story:

I work HH in the pt's sister's home for 12 hrs every week. Last noc at 8 PM the pt had a major BM. It was all liquid. Today, sister insisted that the pt have a BM. She said that the pt could NOT go without one r/t ammonia buildup. I did my weekly assessment, including BS. They were hypoactive. I had to listen for 2 full minutes to hear them. Anyway, the pt had a upper scope run Thursday. She had a small ulcer that "could" have been old. The MD ordered prevacid for 3 wks and then prn. Sis decided that pt didn't need the med so didn't get the script filled. No varicies were visible and for being in liver failure, she looked great.

Anyway, sis told me to give pt a fleet enema at 5 PM. I started the enema and she started crying. I thought that I had put it in her lady parts so I checked her manually. There was no poop! I gave the rest of the enama, and waited 30 minutes. I checked her and all the water had come out with no results except for a tiny smear.

I appologized to the pt for putting her through the pain and discomfort of the enama. I felt really bad.

At 8 PM sis came into the room and asked if she had pooped. I told her no. She told me she was going to take out the trash because the cans were full. She went into the kitchen and searched the trash for the damned fleet bottle!! :angryfire :angryfire :angryfire

She came back into the room and asked me for the container. I had no idea what she was talking about. She finally said she wanted the fleet bottle. I walked over to the small trashcan, pulled it out and gave it to her. She said she was going to give her a "water enema". I repeated that I had given the pt the enema as ordered and that I had NEVER given one with no results. She stated that I should have told her sooner that the enema didn't work!!!

She was pi**** that it didn't work. She kept saying, "she has to poop." I can't make the lady poop! I tried. Have you ever given an enama and not gotten anything? Is this normal?

Here is what she gets in a 24 hr period: TNP 1000 cc. 90 cc's every hr x 11 hrs. 1000 cc's H2O + 4 oz baby food.

Hx: CVA, hepatic failure, resp. failure, ICH.

One other thing, I talked to one of the other nurses on the case today because I couldn't find the MAR. [The nurse that lives close took it home with her. Another story.] Anyway, the RN I talked to said that the sister is in her manic state. I need to know if I should ignore the fact that she accused me of not doing my job, or if I should tell my boss.

Thanks!!!

[kukukajoo, LPN]

Isnt giving a straight water enema bad in some cases?

on as aside, I woud make certain to keep very good documentation on this case to CYA!

[ktwlpn, LPN]

The sister is a perfectionist. She has also taken care of her sister for 4 yrs. She does care but I am concerned.............

As far as social services, I doubt if it will happen. QUOTE] Your agency has social workers,correct? YOU can get them involved. Also -is the patient elderly? If she is I think you should call the office of the aging and get them involved right away.It sounds as though the sister will just keep going from doc to doc and agency to agency.Get the office of aging in there to protect this woman from her sister's love.... You have very legitimate concerns regarding this patient's care.,Of course her sister cares but it sounds as though she is not rational.

[Faeriewand, ASN, RN]

Asterixis: A hand flapping tremor-a sign associated with hepatic encephalopathy, a CNS manifestation of liver failure due to toxic levels of ammonia in the blood.

We just finished a unit on liver disorders in class.

[suzanne4, RN]

It is not Social Services that should be involved, most agencies do not have those depts, but Adult Protective Services of the county needs to be notified.

The physicians are ordering medications for the patient, and the sister is deciding what she should get and not get, but do not see anywhere where a medical degree is listed by her name. And if a GI doc ordered the Prevacid, and she is not getting it, then she is not following their orders and she did have history of an ulcer.

It may need to be taken out of the sister's hands for providing care for her sister. Does not matter that it has been for four years, but the fact is that treatment is now being withheld when ordered. And three different physicians in six months shows issues with the primary caretaker, not the caregivers.

[jnette, ASN, EMT-I]

Does this pt. usually have a BM daily? Does her doc WANT her to have one daily?

As stated above, we do not intervene unless no BMx3 days, and even then it wouldn't be an enema.

But to answer your question, yes.. I have had a hemiplegic pt. (waist down) to whom we gave enemas on a regular basis. Quite often one enema would NOT do it. We did get MD approval to administer another after 45 min. if no BM. The second one would do it for him, but even then it would be a good half hour.

I'm just curious as to what this patient's MD wants re her bm's... as opposed to her sister's wishes.

[P_RN, ADN, RN]

Don't they usually get neomycin and/or Lactulose for this? If there isn't any fecal matter in the rectum or sigmoid there WILL be with the above. The sister is correct in that if she gets ammonia buildup she will go into encephalopathy which isn't pretty. How old is the patient (range in years no specifics)?

editied: I see she gets Lactulose-oh my poor lady

[core0]

Don't they usually get neomycin and/or Lactulose for this? If there isn't any fecal matter in the rectum or sigmoid there WILL be with the above. The sister is correct in that if she gets ammonia buildup she will go into encephalopathy which isn't pretty. How old is the patient (range in years no specifics)?

editied: I see she gets Lactulose-oh my poor lady

Generally Neomycin isn't used anymore due to ototoxicity. Xifaxan and Lactulose are the mainstays. To the OP. Sometimes when a patient is really impacted one fleets does not work and I will try a second one four hours later. However in the setting of large amounts of lactulose and decreased bowel sounds I would suspect an obstruction.

The signs of encephalopathy have been well described. Ammonia is produced in the colon by bacteria feasting on certain proteins. In normal circumstances it is absorbed and converted into urea in the liver which is excreted in the bile. In people with end stage liver disease they cannot process the ammonia in the liver and they frequently shunt blood around the liver through collaterals. This will increase their serum ammonia.

Neomycin and Xifaxan work by reducing ammonia producing bacteria in the gut. Lactulose works in a number of ways. It acidifies the gut which decreases the number of ammonia producing bacteria, it moves stool through faster allowing less time for the bacteria to produce ammonia and it serves as an alternative food source which cause the bacteria to produce less ammonia.

The real problem is there are people that get encephalopathic with normal ammonia and people who are not encephalopathic with high levels of ammonia. Some people feels this argues against Ammonia as being the only cause of encephalopathy. Generally however, if someone is encephalopathic at a given ammonia level they will continue to be encephalopathic at that level. So ammonia by itself does not measure encephalopathy but may tell you something about the individual patient.

Also high dose lactulose can cause an ileus. Something else to consider. At the doses you are giving I would expect 10+ BMs per day.

David Carpenter, PA-C

[leslie :-D]

the bottom line is something must be done for this pt.

she has hypoactive/diminished bs and current interventions are not working.

let's forget about the sister, and start focusing on this pt.

it sounds like an obstxn, nothing to play around with.

leslie