What is the initial nursing intervention if the patient complains of pain or cramping during enema?

General Information

It is possible for enough slowing to occur in the movements of the intestine that the contents become excessively dried and hard. If this occurs at the outlet, just above the anus, fecal impaction may develop. Impaction is a mass of fecal material that is too large or too firm, or both, to pass through the anus.

Impaction may form in a setting of simple constipation. It is also common in association with neurologic problems that extend to involve the nerves and muscles in the pelvis. Strokes and dementia are common antecedents. Because many of these problems occur with aging, the problem of fecal impaction is frequent in elderly patients.

Symptoms associated with fecal impaction are highly variable. Some patients feel a sense of fullness, others of urgency, and others of an incomplete bowel movement when they finish evacuating. Some patients may have no sensation that there is anything wrong at all.

Patients with impaction may complain of constipation. Although it seems paradoxical, some patients with impaction complain of diarrhea. Watery or soft feces pass around the impaction, seeming to be diarrhea. The impaction may so alter the dynamics in the rectum that patients have incontinence.

BASIC INFORMATION

Fecal impaction

In frail patients, fecal impaction may present as a nonspecific clinical deterioration; more specific symptoms are anorexia, vomiting, and abdominal pain. Findings on physical examination may include fever, delirium, abdominal distention, reduced bowel sounds, arrhythmias, and tachypnea secondary to splinting of the diaphragm. The mechanism for the fever and leucocytosis response is thought to be microscopic stercoral ulcerations of the colon. A plain abdominal radiograph will show colonic or rectal fecal retention associated with lower bowel dilation (Figure 108-2). Presence of fluid levels in the large or small bowel suggests advanced obstruction; the closer the fecal impaction is to the ileocecal valve, the greater the number of fluid levels seen in the small bowel.

Disimpaction

If the patient has fecal impaction, disimpaction is necessary before initiation of oral maintenance therapy. A fecal mass can be identified by physical examination in the lower abdomen, rectal examination, or radiographic methods. A typical symptom of fecal impaction is overflow incontinence. Disimpaction has been traditionally accomplished with bowel washouts, but oral medication is effective, too.55,56

Oral disimpaction can be accomplished by high doses of stimulant laxatives, docusate, mineral oil, and polyethylene glycol-electrolyte (PEG) solutions.54,56 Osmotic laxatives such as lactulose or sorbitol can be used in combination with other medication. Oral disimpaction is often associated with abdominal pain and colic, as well as an initial increase in fecal soiling.

Rectal washouts usually work faster than oral disimpaction. It is, however, invasive and painful, especially in patients who have associated anal pathology. Therefore rectal disimpaction is contraindicated in children with anal fissure. Saline, docusate, mineral oil, or phosphate enemas are recommended by different investigators.53,57,58 When rectal disimpaction is used, it is essential that the number of enemas is kept minimal. Usually one to three washouts are required for complete disimpaction. In recalcitrant cases manual evacuation under general anesthesia may be considered.

Enemas

Enemas can be used for fecal impaction. They induce bowel movements by softening hard stool and by stimulating colonic muscle contraction in response to rectal and colonic distention. An oil retention enema (120 mL vegetable oil), followed by a tap water enema (500 mL/day), is generally preferable to salt-containing enemas (phosphate and soapsuds enemas) because oil and water are less irritating to the rectal mucosa. Bisacodyl suppositories or phosphate enemas may also be used to empty the rectum if the stool is relatively soft. If the stool is very hard, then a small-volume (60 mL) rectal oil enema may be used first. Gentle, low-volume enemas can be used through colostomies by experienced nurses. Enemas should be used cautiously in patients with a history of bowel stricture or recent lower bowel surgery and in immunocompromised patients.

Stercoral Ulcers

Stercoral ulcers are defined as lesions that occur due to fecal impaction; they are therefore more commonly encountered in the distal colon. Ulcers typically develop following periods of severe constipation. Patients complain of severe constipation, abdominal pain, rectal pain, pain on defecation, and bleeding. The endoscopic appearance of stercoral ulcers is characteristic. Most lesions are small, range in size from a few millimeters to a few centimeters in diameter, are normally well demarcated, and are superficial in nature. The adjacent mucosa is frequently edematous and congested. Within the ulcerated area, there is tissue necrosis with loss of the epithelium and fibrin deposition in the lamina propria. Hemorrhage and entrapped fecal material may be present as well. With time, granulomatous inflammation and foreign-body-type giant cells develop in areas of entrapped fecal material.

The treatment of stercoral ulcers is mainly supportive. This includes the use of stool softeners and dietary modification. Most cases heal without sequelae. However, rare cases may be associated with colonic perforation, strictures, and obstruction.

Treatment

Treatment goals in the emergency care setting include evacuating a fecal impaction, if present, by either oral or rectal administration of medication. Osmotic agents in large doses can be given orally, and phosphate soda or mineral oil enemas can be administered rectally. Glycerin suppositories may be used in infants and bisacodyl suppositories in older children. Once the initial evacuation has been successful, or when a child without impaction has been fully evaluated, maintenance treatment can begin.

Maintenance therapy involves medication, patient education, diet modification, bowel retraining, and long‐term monitoring by parents. Medications include osmotic agents (e.g., MiraLax, lactulose), which cause water to be retained within the stool, stool softeners such as Colace (docusate sodium), and bulking agents such as psyllium. Generally, children should not be given stimulant laxatives and oral mineral oil products because the former may dehydrate the patient and the latter can cause aspiration pneumonia and rectal leakage, as well as deficiencies of vitamins A and D.

Educating and counseling parents helps remove their anxiety regarding their child's health; they need to understand that encopresis is not a purposeful, defiant behavior; that all family interactions regarding the issue be positive; that adequate levels of exercise increase bowel motility; that this condition is subject to relapse and requires patience: and that constipation requires long‐term treatment but treatment can be successful.

Diet modification is also part of long‐term maintenance of healthy bowel habit, but this should not be forced upon the child. Diets that include absorbable carbohydrates like sorbitol, found in prunes, pears, and apples, can soften stools. A diet including grains, fruits, and fiber is recommended, as well as sufficient fluid intake.

Bowel retraining is just as important for success. Parents need to ensure a scheduled 5–10 minutes of “toilet time” after every meal for the child, adjusting this frequency to the child's age and gradual improvement.

Maintenance interventions should be continued for a period of 6–12 months until the rectal vault has resumed normal size and tone. Subsequently, parents should monitor the frequency of stooling; if 2 or more days pass without a bowel movement, interventions should resume promptly.

Stercoral Ulcer

Stercoral ulcers are longitudinal mucosal tears or perforations that result from fecal impaction. They occur most frequently in the distal colon and rectum. Patients typically present with severe chronic constipation, pain, and rectal bleeding. The hard, impacted fecal material causes localized pressure, ischemia, and subsequent necrosis of the mucosal surface. The ulcers may be single or multiple and usually have sharply defined edges and there is congestion of the adjacent mucosa. Most lesions are confined to the submucosa, but deeper ulceration and perforation can occur. Biopsy may be obtained to exclude other inflammatory causes of ulceration or neoplasia. Histologic sections of the early lesions reveal ischemic injury with extensive necrosis and entrapped fecal material, vascular congestion, and patchy hemorrhage. Chronic ulcers show reparative changes, fibrosis, and inflammation and may exhibit a granulomatous response to the fecal matter.