You need an order to remove a fecal impaction digitally right?

[lashuna1028]

One of my problem patients was complaining of not have a BM in 7 days. I did my assessment and all okay with abdomen. She requested a suppository, I told her I will have to call MD for order. So before I could get to it, she calls her husband crying on phone. He comes rolling in with his wheel chair and bang his walking cane on the counter saying I need to "make it snappy! or else she going to have to go to the hospital" (Just giving you a picture of what this couple) You know how the elderly are obsessed with their bowels. I explained to him that I am trying to get a hold of a MD to get orders.

I finally reach MD and get orders for stat KUB and 1 ducolax supp. When I go into room and explain orders they change mind, refused supp and said I need to take it out digitally, I told him no and that req an order from MD, then he started explaining another nurse did it for her... blah blah.

They finally agreed for supp, so I gave it. At time didn't feel impaction...

I went ahead and gave DON a call because like I said this is a problem patient that exaggerates and throws everything out of proportion. You know the ones that says someone hit them or stole this and that, etc..

But she tells me I didnt need an order for digitally removing a fecal impaction... Am I going crazy or what? Which is it?

[Pretty in Ink]

I have disimpacted a pt. w/o a dr's order before but that was because she was sitting on the commode crying in pain. Other than that, I would check for impaction, if there was I would notify the Dr. and ask for an order b/c they might order something else like an enema or something along those lines. If the pt. has any cardiac problems DO NOT digitally disimpact her. Sounds like she may just need to be monitored daily, have her fluids increased maybe some GoLytely and increase her activity level if possible. And you aren't lying about the geriatric population being on top of their bowel situation!!! My goodness!!!! lol...

[nursejoy1, ASN, RN]

In the LTC facility I work at, it's pretty much routine and the MDs expect us to use our nursing judgement on it. Ducolax Suppositories are a standing order for everyone unless they have allergies or contraindications.

[CoffeeRTC, BSN, RN]

YES!! You do need a doctors order for it. Things can happen, but if the baby is crowning, some times you need to help with the delivery.

Its been many a year since I've needed to do this. We are big on prevention.

So...if this resident had it done once.....why does she need it again? What orders were put in place to prevent this? Why did it take 7 days? The state would have a field day with this one.

[Vito Andolini]

This must depend on where you work, what the policies are at each facility, that is. Too bad your doctor and your Director don't arrange for patients to have standing orders for such common, common problems. Every patient, unless contraindicated and then the chart should so state, should have orders for:

Tylenol for pain, fever

MOM

Cleansing enema (old fashioned soap suds or modern convenient Fleet's)

Dulcolax suppository

Benefiber

Lactulose

Colace

Pericolace

muscle rub for achy muscles

heating pad

cold pad

Benadryl po and topically for itching (or hydrocortisone, calamine lotion, or oatmeal bath)

sleeper for insomnia

warm saline soaks for sore feet and various small lesions, such as redness around fingernails

PRN eye, Podiatry, GYN, dental, etc. consults

antibiotic ointment for minor scratches

vaseline for rectal itching or other minor skin irritations or dry skin

and various other standing orders for common, minor problems.

So much pain and suffering, so much nursing time could be saved if nurses had some standing orders like these, written on each chart and signed by MD/DO or NP or PA upon admission. Less having to bother doctors, too.

I know some of these

[DaMale Nurse]

In my work I always go with I need a doctors order unless it specifically states I can do that in my policy and procedure manual. Since I work with pscy geratric pts it can get interesting when talking about bowels. I always love the guy who takes 4 fibercare every time there is a new staff giving meds and ends up spraying the walls of his bathroom on my shift. But you arn't kidding about the obsession with bowels.

[Chaya, ASN, RN]

I've found this varies. I worked in a Rehab where it was up to the nurse's judgement if disimpaction was needed. I work in an acute facility now where we are supposed to get an MD order, the thinking being that the pt can have a vagal response.

[nightmare, RN]

We used to be able to just digitally remove impaction.Nowadays ,however it is seen as a form of abuse!!Now you need to do an assessment,have the person's permission and be competent to do the procedure.

[sharlynn]

I've never worked anywhere that required an order.

[CapeCodMermaid, RN]

I would not, nor would I let my nurse, disimpact anyone without an order. If you think there is a fecal impaction and not just a blockade of hard stool, you'd better do more than manually remove it. Most true impactions are higher up than you can feel with your finger. AND if it is truly a fecal impaction, it is considered a SENTINEL EVENT and must be reported to the DPH.

As far as the list of standing orders one of the other posters gave:

Benadryl is on the BEER'S LIST and shouldn't be used in people over 65.

Antibiotic ointments for the most part cause over growth of other bacteria and yeast and should be used sparingly, if at all.

The best things for someone's bowels...fluids,high fiber foods, and activity, not pericolace, senna and other drugs.

[Nascar nurse, ASN, RN]

In my state it is illegal to have "standing orders" for anything. We have to have signed Drs order for every med and tx.

It seems silly to me to write that huge long list of PRN stuff, track the Dr. to sign it, order it & thereby the facility or resident has to pay for it, and then maybe never need it! Not good common sense when an ounce prevention could save lots of money and trouble.

Bottle of MOM = $5

One Fleets Enema $7

One tall glass of prune juice every morning= priceless

(Being goofy today - sorry)

[Chaya, ASN, RN]

In my state it is illegal to have "standing orders" for anything. We have to have signed Drs order for every med and tx.

It seems silly to me to write that huge long list of PRN stuff, track the Dr. to sign it, order it & thereby the facility or resident has to pay for it, and then maybe never need it! Not good common sense when an ounce prevention could save lots of money and trouble.

We have these printed order sheets for each dx with a box to check off beside each individual order and a line for the doc to sign on the bottom