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Standard Number:




Effective Date:




Interprofessional Practice & Clinical Standards

 Policy X Guideline  Protocol  Procedure  Plan of Care




Professional Responsible:


Registered Nurse / Licensed Practice Nurse

Title:

Guideline for the Care of a Resident / Patient Who is Impacted

Indications:

Indications of fecal impaction include a dilated rectum, abdominal distention and possibly pain, rectal discomfort and/or a feeling of fullness, painful defecation and a palpable fecal mass in the rectum. Impaction may also result in an overflow incontinence of small amounts of liquid stool (bypassing), which occurs as a result of mucosal irritation above the fecal mass.

Symptoms characteristic of impaction in the elderly may also include sudden delirium, urinary frequency, incontinence or retention.




Care Outcomes:

To prevent or appropriately treat constipation and thus avoid fecal impaction. If impaction occurs, the goal is to accurately assess and treat the impaction and, once resolved, to evaluate and revise the plan of care to prevent a recurrence. If untreated, fecal impaction high in the rectum or in the sigmoid colon can lead to bowel obstruction, resulting in a crisis situation for the resident/patient.


Definitions:

Fecal impaction is defined as an accumulation of hard feces in the rectum or sigmoid colon that cannot be expelled by normal intestinal contractions or with the use of laxatives or enemas.


RELATED STANDARDS:

  1. Guideline for the Care of Residents / Patients with Constipation

  2. Procedure for Disimpaction


SUPPORTIVE INFORMATION:

ASSESSMENT: Level 1 – Identification of the high risk resident / patient


  1. Resident who has had a previous impaction.

  2. Resident who has not had a BM for 5-6 days in response to oral and rectal laxatives



ASSESSMENT: Level 2 – Assessment for Impaction


  1. Assess abdomen for distention and rigidity. The resident/patient may indicate that they feel the need to defecate but cannot do so. If a mass is palpated in the lower left abdomen, it may be impacted stool in the sigmoid colon.

  2. Assess for rectal pain and for areas of tenderness in the lower abdomen.

  3. Perform digital rectal examination to assess for hard stool in the rectum, possibly accompanied by rectal distention.

  4. Determine if the resident/patient is bypassing small amounts of stool and mucous around the fecal mass. The bypassing stool is often the consistency of gravy and bypassing occurs frequently throughout the day.

  5. Assess for recent onset of acute confusion or other significant change in behavior.

  6. Assess for recent onset anorexia, with or without nausea and lethargy.

  7. Assess for recent onset urinary frequency, retention or incontinence.


INTERVENTIONS:


  1. If the resident / patient is able to wait, call the GP and ask for an order for an anaesthetic gel / ointment such as Lidocaine before beginning disimpaction.




  1. . If hard stool is present, give an oil retention enema to soften the stool before any further intervention. Once the stool is softened, a fleet can be given to assist the resident/patient to pass the fecal mass at the nurse’s discretion.




  1. If the fleet is not successful or the mass is too large to pass, manual disimpaction is indicated. See the procedure for manual disimpaction. Note that excessive rectal manipulation may cause irritation of the mucosa, bleeding and stimulation of the vagus nerve, which can cause a reflex slowing of the heart rate. If these occur, disimpaction should be discontinued, the problems charted and the physician contacted. Disimpaction may be resumed the following day after discussion with the physician.




  1. Following removal of the fecal mass, give an oral laxative at HS to move any remaining stool into the rectum and an enema the following morning to ensure that the rectum is clearing.




  1. If there is no stool in the rectum but stool is evident in the colon on examination of the abdomen, call the physician to discuss the need for an abdominal x-ray.



EVALUATION


  1. Once the fecal mass and accumulated stool have been evacuated, it is imperative to evaluate previous bowel care and revise the interventions as necessary to avoid further episodes of impaction. It is appropriate to discuss alternate interventions with the GP and the Nutritionist. A LPN must discuss treatment options with an RN before changing the care plan.



DOCUMENTATION


  1. Impaction is considered an unusual event, therefore the current problem of impaction and the interventions, including the resident’s/patient’s response to the interventions, is documented on the progress notes and communicated to the physician.

  2. All residents/patients on a protocol for impaction must have a problem identifying the potential for future impaction documented on a care plan.

  3. Once the impaction is resolved, appropriate assessment & interventions are documented on the care plan to avoid further problems with impaction.


References:


  1. Jensen LL. Assessment and management of patients with bowel dysfunction and fecal incontinence. In D. Doughty (ed) Urinary and Fecal Incontinence: Nursing Management. (2nd Ed). Mosby; 2000: 353 – 383.

  2. Prather, C & Ortiz-Camacho, C. Evaluation and treatment of constipation and fecal impaction in adults. Mayo Clin Proc. 1998; 72: 881-887.

  3. Wrenn K. Fecal impaction. New England Journal of Medicine. 1989; 321: 658-662.

  4. Alessi, C & Henderson, C. Constipation and fecal impaction in long term care patients. Clinics in Geriatric Medicine. 1988; 4:571-588











Author(s): Seniors Health Program CNS / CRN Group







Issuing Authority: Seniors Health Nursing Practice Committee







Date last reviewed /revised: August 2003




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