Question

The nurse is preparing to manually remove the fecal impaction on an 80 year-old client. What information is the most important to understand before performing this procedure?

1. The presence of hemorrhoids is a contraindication for manual removal of the impaction
2. The client may experience bradycardia during the procedure
3. The procedure should be done prior to a bath
4. Increased dietary fiber, fluids and activity can minimize fecal impaction

Answer 1

Before performing a manual removal of a fecal impaction, the nurse should consider contraindications, potential bradycardia, and timing in relation to a bath.

Step-by-step explanation:

Before performing a manual removal of a fecal impaction on an 80 year-old client, it is important for the nurse to understand that:

1. The presence of hemorrhoids is a contraindication for manual removal of the impaction. Hemorrhoids can be easily aggravated or injured during the procedure, causing pain and potential bleeding.
2. The client may experience bradycardia during the procedure. The stimulation of the rectal area can activate the vagus nerve, which can slow down the heart rate.
3. The procedure should be done prior to a bath. A warm bath or sitz bath can help relax the rectal muscles and facilitate the removal of the impaction.

Increased dietary fiber, fluids, and activity can minimize the risk of fecal impaction, but they are not specific considerations for the procedure itself.