When a Confused Patient Smarter than a Doctor

macawake, MSN · Dec 7, 2013

Yesterday I had a new admit with new onset of mental status change. The first thing the pt did after arriving to the nursing unit from emergency room - he had a bowel movement. Then I reviewed doctor's orders, enema was ordered. I called doctor and informed him that the pt already had BM. Doctor said that the pt still needs enema because CT of abdomen showed stool in colon. I read CT report. Nothing was mentioned about stool in colon in radiology report. If not mentioned I assumed that colon was WNL, why to give enema? But doctor still thought that enema needed. I told the confused pt about doctor's order, to my relief, pt refused, stating that he just had BM. Yes, sometimes confused patients can be smarter that doctors.

I'm not sure I understand your post. Why did the doctor order the enema? "Stool in colon" seems like a rather everyday occurrence... and not a problem in most cases.

What was your patient's medical history? Status and current complaint/s? Presents with new onset mental status change, anything else? What tests were done? Any medication given?

When was your patient's last bowel movement prior to the one that took place at the hospital?

Did the patient complain of constipation/stomach pain?

Were any procedures like a colonoscopy planned?

Was there any suspicion of hepatic encephalopathy? (An enema would be unusual as far as I know, I'm used to giving conscious patients p.o. laxatives for this.).

Why are you relieved that your patient refused? Do you feel that the enema would have been detrimental to your patient?

On a tangent, what I usually see in the radiology report is the answer to whatever question/s the physician asked. An abdominal scan won't always/usually mention the presence of stool. Just because it isn't in the text however, doesn't mean it can't be seen on the picture/film.

applewhitern, BSN, RN · Dec 7, 2013

I doubt the doctor just made that up, just so you'd have to do an enema. Sometimes people have a LOT of stool and need help, such as with an enema. Sometimes they stool around an impaction, too.

cardiacfreak, ADN · Dec 7, 2013

I was thinking the same thing, IMPACTION. Just because he had a BM doesn't mean he doesn't have more in there. Was the BM he had loose or runny? If so, he is probably going around the impaction.

Pepper The Cat, BSN, RN · Dec 7, 2013

Yes. Impaction. The rectal area may be clear, but there may be more still up in the colon.

Ruby Vee, BSN · Dec 7, 2013

I guess I would want to make sure I understood WHY the doctor ordered the enema and what the goals were. If the patient has a fecal impaction, it's possible to have loose or runny stools AROUND it, but the impaction would still be there. In that case, an enema would be indicated. But from the tone of your post and what was said, I get the impression that there wasn't effective communication between you and the physician. Before you conclude that "the confused patient is smarter than the doctor", you need to understand the treatment plan and goals.

brownbook · Dec 7, 2013

I understand the responses but you clearly stated the CT scan said nothing about stool in the colon. I'm glad the patient refused. It doesn't sound like a medical emergency? I would have handled it as you did. However I hope you notified the Dr. that the patient refused. If so what did the Dr. say?

Gosh, certainly Dr.s' can make mistakes, sounds like you advocated for your patient.

WillyNilly · Dec 8, 2013

With impactions, pts can present with MS change. I have seen a enemas given and pt clears stool and MS clears as well.... Especially in geriatric patients or dementia.

Just a thought

cardiacfreak, ADN · Dec 8, 2013

I thought of this post last night while I was at work. I had a patient that had not, he stated, had a BM in 3 weeks, although I highly doubt it was 3 weeks. Anyway, I had an order for fleets enema and if no results follow up with soap suds enema. I guess it is important to say that this order had been written by the doctor at 1300. The day shift nurse told me she just didn't have time! Ok no big deal, I don't love poop but it is a something that nurses have to deal with.

I go in and assess my patient. He is a middle age man with stage 4 cancer being treated with chemo and radiation, he has generalized pitting edema, oh and did I forget to mention 2 chest tubes for a pneumothorax. He was grumpy and in a lot of pain in the abdominal area. I explain to him what my plan of care is going to be, and he doesn't really care. So I tell him, "My goal for the night is to get you to have a bowel movement." He responds, "Whatever."

I gather my supplies, and have my CNA come with me. She was none to happy either, "Oh my gosh, he's going to be pooping all night long." To which I reply, "Well, don't you poop?"

I give the fleets enema, of course no result, the poor guy can't hold anything in there. I try the soap suds enema a little while later, same result, he can't seem to hold anything. Now I know it is not advised for nurses to digitally remove an impaction but the guy is desperate and so am I, I only wanted to determine if I could feel the stool and if so I would call the doctor and get an order for digitally removing. However the stool was very soft and up a little bit too high.

I finish assessing him, and tell him I would be back in a short while to check on him. I move on to my next patient who was on peritoneal dialysis. As I am assessing her, he calls me on my Vocera and says he needs the bedpan. I go back to his room and call for someone to come help me get him up, it takes 2 of us and a walker and we get him to the BSC. He had made a little mess in the bed and he was upset, I say to him "Hey, I don't care if you do it on the floor, we've got to get that out of you." While I am changing his bed he finally let loose, he was thrilled, we chatted some about pain meds making a person constipated, and talked about things he can eat to help with that.

After we got him cleaned up and sitting on the side of the bed, he wanted to see his results, so I showed him, it was probably the largest BM I have seen in my whole 23 years of doing this. He looked up at me and said, "What color are my eyes?" I look and tell him that they are a very pretty blue. He then tells me, "They've been brown for 2 weeks." We both have a laugh at that, and he gets settled into bed.

The next morning as I am giving the same dayshift nurse report he tells her, "Hey, you should take some pointers from her, she really knows her sh*t."

OCNRN63, RN · Dec 9, 2013

With impactions, pts can present with MS change. I have seen a enemas given and pt clears stool and MS clears as well.... Especially in geriatric patients or dementia.
Just a thought

Sometimes people really do have **** for brains. (j/k)

cardiacfreak, ADN · Dec 9, 2013

Sometimes people really do have **** for brains. (j/k)

Thanks for the laugh.

Tfulton · Apr 26, 2016

I'm not a nurse, but found this on a google search and have a similar story. I was recently in the er with abdominal pain and discomfort. A ct scan was ordered and I was told there was a lot of material in my colon. I was given an oral laxatives and iv magnesium sulfate I believe. When no results were obtained, a bottle of magnesium citrate was ordered. I told the nurse I'd had bad cramping with this before and asked if I had to take it. She curtly informed me that, no I didn't, but then the dr would probably just order an enema. I wasn't given much time before she was back with a Fleet enema, which I didn't want, but didn't feel like I could refuse. It was given and no results were obtained. I was then informed that soapsud enemas would be ordered. I told her and the dr that I didn't really think I was constipated but they insisted. They wound up giving me three large enemas that night which were not fun by any means. After the third however, it all broke loose and I felt immense relief after a while. So, although I disagreed with the diagnosis and treatment, in the end (some pun intended) I was saved from impaction.