Fecal Disimpaction

Hi, I'm a new grad nurse working at an assisted living facility. A nursing student reported that one of our resident has 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 hessitant to do the dis-impaction because of 3 main reasons: 1, never did it before and i am unsure of all the precautions to take when doing this procedure. 2, Im not sure if there are any special precautions needed for people actively bleeding. and 3, I dont even think its 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, its been bothering me all night last night and made me look at my supervisor a different way now.
Might be hemorrhoids.

Manually removing fecal impactions is risky with too many potential problems that could arise. Best thing to do is call the physician & get an order for an oil retention enema (suppositories do not work on impactions) but if there was bleeding present I would have sent them in to the clinic or ER for an exam. Don't ever let any nurse tell you manually removing impactions is OK. Did you have a doctor's order to remove the impaction...thats another thing you could have told your supervisor if you didn't have an order. Don't let a supervisor bully you if you feel something is unsafe, you will learn to assert yourself the longer you are in nursing! thanks,Jerenemarie

I have only had to disimpact a couple of times, but one thing you should watch out for is if they have an extensive cardiac hx such as heart block, CHF, etc. Just keep your eye on their heart rate - I have had a pt vagal down pretty low and had to stop the disimpaction.Like said above, I would definitely get an MD order to do this and since you haven't done it before or even if you have and feel uncomfortable, ask for help. You should not have to do stuff like this on your own the first time.The nursing student disimpacted your patient on his/her own? That is not cool, I would speak up about that.

I was taught never to manually disimpact. The risk is too high. That student nurse and your supervisor were way out of line. You should discuss this with the student and the clinical instructor. As far as your supervisor goes she is just plain lazy!

Does this vary by state? We are taught how to manual disimpact in first semster and as long as we have cleared it with our nurse and our instructor is present we can do one. We don't need a physicians order. It's concidered nursing judgement. I have never given one, but I have assisted in holding other students patients while they performed the disimpaction. This is the first I've heard nurses say that it shouldn't be done and it needs an order from the MD.

I'm a bit taken aback to hear that some nurses are being taught that manual disimpaction is "too risky" or requires doctor's orders to perform. Although my experience is primarily in the spinal cord injury/damage population, I've always understood this to be a fairly standard practice and within the realm of the nurse's discretion.Your supervisor exercised very poor judgment by insisting you perform a procedure that you've never done before on your own.

The state of Minnesota looks at impactions as a BIG problem...one of the first questions they have is the patient dehydrated or not & what type of meds are they on to contribute to the problem (psychotropic meds which cause dry mouth, etc). I'm speaking from a Long Term Care point of view. If an MDS is submitted with "impaction" listed, that immediately raises a big flag for the survery team. Again, this is how impactions are looked at in the elderly population, I have no idea how acute care deals with it. Also manually removing an impaction is very uncomfortable for the elderly plus it can cause a vagal episode. I would hate to be a nurse disimpacting someone who "passes out cold" on me, especially if I didn't have a doctor's order!thanks!Jerenemarie

Off topic somewhat, but nonetheless interesting: http://researcher.nsc.gov.tw/public/...3012523371.pdf

Well, look folks. When did digital disimpaction turn into something that was beyond nursing's scope of practice. Some of the stuff that's been mentioned is certainly true, and besides, the procedure is not comfortable, stressless or soothing, and there are some risks... But, are we professionals or... do we throw up our hands and play pitiful? There is still this thing called the nursing process, yes?OK... there is a chance for a vagal response when you stimulate the rectum. But being impacted and straining at stool can do the same thing.Yes... disimpacting someone will traumatize some tissues... as will a big wad of dry stool the patient can't move.Yes... you'd have to assess for rectal bleeding (and is the patient on anticoagulants? How bad are those hemorrhoids? There isn't any chance of increased portal pressure, right? You say the patient is bleeding? Is it a lot? If so, what are his coags? Blood in the linen should prompt some thinking and further assessment.)Exactly how long ago was the last BM? What is his/her abdominal assessment? Are they eating? Are they drinking? Are they on anticholinergics or opiates? Do they get out of bed? Are they getting their stool softeners? What diet are they on? Is there something else we can do to help them because... this is at the absolute bottom of my to-do list.Um... I've worked in 6 different states and it's been a nursing judgement. Yes, the MD is in the loop and if you need a second opinion, sure... talk to the MD first. But come on folks.

At our facility disimpactions require a Dr's order (LTC). To be honest Ive seen nurses do it w/o an order though. Not sure how they get by with it. I do not know why they require a dr order, in nursing school we were taught that it is a nursing judgement call as stated by other posters. Maybe its just a LTC thing??

When I read the origonal post it smelled (so to speak) an a lot like troll bait to me.

I think this could be a legit post. I think this is another example where nurses are not supported by management.